Medical Policy Bulletin

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Section:	Miscellaneous
Number:	G-19
Topic:	Professional Component for Pathology Tests
Effective Date:	January 1, 2012
Issued Date:	January 2, 2012
Date Last Reviewed:

General Policy Guidelines

Indications and Limitations of Coverage

Generally, there is no identifiable personal physician involvement in a clinical pathology test. Claims reporting only the professional component of clinical pathology studies should be denied in all places of service. Further, claims reporting clinical pathology studies (total charge) rendered in a hospital setting (in-hospital or outpatient hospital) or skilled nursing facility should be denied.

Conversely, anatomic pathology studies require physician interpretation. Claims for these tests performed in the physician's office or an independent laboratory should be reimbursed as a total service unless otherwise reported. Anatomic pathology performed in a hospital setting (in-hospital, outpatient hospital or skilled nursing facility) should be paid as a professional component.

The following procedure codes designate anatomic pathology studies (although some of the services listed may not be eligible for payment):

85097
85396
88000-88099
88104-88106
88108-88199
88230-88299
88300-88314
88319-88399
89250-89257
89260-89261
89268-89281
89300-89325
89335-89356
G0123
G0124
G0141-G0148
G0416-G0419
P3000
P3001
0058T
0059T

Although the following pathology tests are classified as clinical pathology services, they require personal physician involvement in providing an appropriate analysis of the results. Therefore, when billed, the professional component for these services should be paid.

82131
82486
83020
83912
84165
84166
84181
84182
84999*
85060
85390
85576
86077
86078
86079
86255
86256
86320
86325
86327
86334
86335
87164
87207
89060

* When reported for mass spectral analysis of organic compound with mass spectrometer.

Claims for clinical pathology studies performed out-of-state are reimbursable regardless of place of service or whether or not it is the practice of the Blue Shield Plan of that state.

Description

The total charge for a diagnostic study includes both a professional and a technical component. The technical component is considered to be the performance of the test and is generally performed by non-physician personnel and/or automated equipment. The professional component is the physician's involvement, including interpretation of the test results.

Procedure Codes

82131	82486	83020	83912	84165	84166
84181	84182	84999	85060	85097	85390
85396	85576	86077	86078	86079	86255
86256	86320	86325	86327	86334	86335
87164	87207	88000	88005	88007	88012
88014	88016	88020	88025	88027	88028
88029	88036	88037	88040	88045	88099
88104	88106	88108	88112	88120	88121
88125	88130	88140	88141	88142	88143
88147	88148	88150	88152	88153	88154
88155	88160	88161	88162	88164	88165
88166	88167	88172	88173	88175	88177
88182	88184	88185	88187	88188	88189
88199	88230	88233	88235	88237	88239
88240	88241	88245	88248	88249	88261
88262	88263	88264	88267	88269	88271
88272	88273	88274	88275	88280	88283
88285	88289	88291	88299	88300	88302
88304	88305	88307	88309	88311	88312
88313	88314	88319	88321	88323	88325
88329	88331	88332	88333	88334	88342
88346	88347	88348	88349	88355	88356
88358	88360	88361	88362	88365	88367
88368	88371	88372	88380	88384	88385
88386	88387	88388	88399	89060	89250
89251	89253	89254	89255	89257	89260
89261	89268	89272	89280	89281	89300
89310	89320	89321	89325	89335	89342
89343	89344	89346	89352	89353	89354
89356	G0123	G0124	G0141	G0143	G0144
G0145	G0147	G0148	G0416	G0417	G0418
G0419	P3000	P3001	0058T	0059T

Traditional (UCR/Fee Schedule) Guidelines

Refer to General Policy Guidelines

This medical policy may not apply to FEP. Medical policy is not an authorization, certification, explanation of benefits or a contract. Benefits are determined by the Federal Employee Program.

Comprehensive / Wraparound / PPO / Major Medical Guidelines

Comprehensive

The technical component of a diagnostic service is eligible when billed by a facility.

Also refer to General Policy Guidelines

Any reference in this bulletin to non-billable services by a network provider may not be applicable to Major Medical.

Managed Care (HMO/POS) Guidelines

Refer to General Policy Guidelines

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Table Attachment

Text Attachment

Procedure Code Attachments

Diagnosis Codes

ICD-9 Diagnosis Codes

ICD-10 Diagnosis Codes

Medical policies do not constitute medical advice, nor are they intended to govern the practice of medicine. They are intended to reflect Highmark's reimbursement and coverage guidelines. Coverage for services may vary for individual members, based on the terms of the benefit contract.

Highmark retains the right to review and update its medical policy guidelines at its sole discretion. These guidelines are the proprietary information of Highmark. Any sale, copying or dissemination of the medical policies is prohibited; however, limited copying of medical policies is permitted for individual use.