Pathology Interpretation Services
March 28, 2016MAC J6 for Wisconsin, Illinois, and Minnesota
MAC JK for Maine, Massachusetts, New Hampshire, Rhode Island, Vermont, Connecticut and New York
National Government Services has noted that there is some confusion and questions regarding the billing of professional components on some laboratory services. There is a certain subset of CPT codes for which are 100% technical but they can be billed with a 26 modifier if a physician interpretation is medically necessary. An interpretation may only be billed for these codes for hospital patients performed by hospital pathologists. They are not reimbursed for an office setting. This is further explained in CMS IOM Publication 100-04, Medicare Claims Processing Manual, Chapter 12, Section 60 (C) – Payment for Pathology Services. Only clinical laboratory interpretation services, which meet the criteria in subsections C.3.a, c, and d, are billable under the physician fee schedule. These codes have a PC/TC indicator of “6” on the Medicare Physician Fee Schedule database. These services are reported under the clinical laboratory code with modifier 26. These services can be paid under the physician fee schedule if they are furnished to a patient by a hospital pathologist or an independent laboratory.