Surgical Pathology Services
Surgical pathology services include the gross and microscopic examination of organ tissue performed by a physician, except for autopsies, which are not covered.
Either the professional component, the technical component or both components may be paid for the following surgical pathology services: 88300, 88302, 88304, 88305, 88307, 88309, 88311, 88312, 88313, 88314, 88319, 88323, 88331, 88332, 88333, 88334, 88342, 88346, 88347, 88348, 88349, 88355, 88356, 88358, 88360, 88361, 88362, 88365, 88367, 88368, 88380, 88381, 88384, 88385, 88386, 88387, 88388, G0416, G0417, G0418, G0419.
Codes 88321, 88325 and 88329 represent physician services.
Cytopathology
Cytopathology services include the examination of cells from fluids, washings, brushings or smears, but generally exclude hematology. Examining cervical and vaginal smears are the most common service in cytopathology. Cervical and vaginal smears do not require interpretation by a physician unless the results are or appear to be abnormal. In such cases, a physician personally conducts a separate microscopic evaluation to determine the nature of an abnormality. This microscopic evaluation ordinarily does require performance by a physician.
When medically necessary and when furnished by a physician, the professional component of the following services is eligible: 88104, 88106, 88108, 88112, 88120, 88121, 88125, 88160, 88161, 88162, 88172, 88173, 88177, 88182.
Codes 88141, 88187, 88188, and 88189 represent only the professional service.
Separate payment for a physician’s interpretation of a pap smear to any patient (i.e., hospital or non-hospital) is eligible as long as:
- the laboratory’s screening personnel suspect an abnormality; and
- the physician reviews and interprets the pap smear.
This policy also applies to screening pap smears requiring a physician interpretation. These services are reported under codes G0124, G0141, or P3001.
Hematology
Physician hematology services include microscopic evaluation of bone marrow aspirations and biopsies. It also includes those limited number of peripheral blood smears which need to be referred to a physician to evaluate the nature of an apparent abnormality identified by the technologist. These codes include 85060 and 85097.
The professional component for the interpretation of an abnormal blood smear (code 85060) furnished to a hospital inpatient by a hospital physician or an independent laboratory is eligible for reimbursement.
For the other listed hematology codes (85390, 85576), payment may be made for the professional component if the service is furnished to a patient by a hospital physician or independent laboratory.
Codes 85060 and 85097 represent professional-only component services and have no technical component values.
Blood Banking Services
Blood banking services of hematologists and pathologists are paid when analyses are performed on donor and/or patient blood to determine compatible donor units for transfusion where cross matching is difficult or where contamination with transmissible disease of donor is suspected.
The blood banking codes are 86077, 86078, and 86079 and represent physician-only services.
Clinical Laboratory Interpretation Services
Only the clinical laboratory interpretation services listed below, which meet the criteria for clinical consultations are eligible. The following services can be paid if they are furnished to a patient by a hospital pathologist or an independent laboratory: 83020, 83912, 84165, 84166, 84181, 84182, 85390, 85576, 86255, 86256, 86320, 86325, 86327, 86334, 86335, 87164, 87207, 88371, 88372 and 89060.
For additional information on screening pap smears, see Medicare Advantage Medical Policy Bulletin L-1.
For additional information on autopsies, see Medicare Advantage Medical Policy Bulletin N-24.
For information on Clinical Pathology Consultation Services, see Medicare Advantage Medical Policy Bulletin N-161.
Reasons for Noncoverage
Codes 80500 and 80502 represent consultation services. Therefore, the technical components (modifier TC) and professional component (PC) concept does not apply.
The following services represent only professional services. Therefore, the technical component (modifier TC) and total component concepts do not apply: 85060, 85097, 86077, 86078, 86079, 88141, 88321, 88325, and 88329.
Claims reporting only the professional component for laboratory and pathology services not addressed on this policy are not covered. A provider cannot bill the member for the denied service.
Documentation Requirements
Medical record documentation should support the service that was reported.
Medical record documentation should support the medical necessity for interpretation by a physician for services listed under Specific Hematology, Cytopathology and Blood Banking Services.
Medical record documentation should support the medical necessity for separate review and interpretation of cytopathology studies.
Medical record documentation should indicate that the requirements for a Clinical Consultation have been met.
Title XVIII of the Social Security Act, Section 1862(a)(7). This section excludes routine physical examinations.
Title XVIII of the Social Security Act, Section 1862(a)(1)(A) states that no payment shall be made for items or services which are not reasonable and necessary for the diagnosis or treatment of illness or injury.
Title XVIII of the Social Security Act, Section 1833(e) states that no payment shall be made to any provider for any claim that lacks the necessary information to process the claim.
CMS On-line Manual 100-04, Chapter 12, Section 60