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.

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
88000-88099
88104-88199
88230-88299
88300-88399
89254-89257
89260-89261
89300-89325
G0123
G0124
G0141-G0148
P3000
P3001

Code/Terminology

82131 - Amino acids, quantitation, each
82486 - Chromatography; gas-liquid, compound and method not elsewhere specified
84999 - Mass spectral analysis of organic compound with mass spectrometer
85060 - Blood smear, peripheral, interpretation by physician with written report.

Clinical pathology tests are eligible for payment regardless of place of service when performed by a physician.

Comprehensive

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