Highmark Medical Policy Bulletin
Section: Miscellaneous
Number: G-19
Topic: Professional Component for Pathology Tests
Effective Date: October 14, 2002
Issued Date: October 14, 2002
Date Last Reviewed: 10/2002

General Policy Guidelines

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

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
84181
84182
84999*
85060
85390
85576
86077
86078
86079
86255
86256
86320
86325
86327
86334
87164
87207
89060

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

Procedure Codes

821318248683020839128416584181
841828499985060850978539085576
860778607886079862558625686320
863258632786334871648720788000
880058800788012880148801688020
880258802788028880298803688037
880408804588099881048810688107
881088812588130881408814288143
881448814588147881488815088152
881538815488155881608816188162
881648816588166881678817088171
881728817388180881828819988230
882338823588237882398824088241
882458824888249882618826288263
882648826788269882718827288273
882748827588280882838828588289
882918829988300883028830488305
883078830988311883128831388314
883188831988321883238832588329
883318833288342883468834788348
883498835588356883588836288365
883718837288399890608925489255
892568925789260892618930089310
893208932189325G0123G0124G0141
G0143G0144G0145G0147G0148P3000
P3001     

Traditional (UCR/Fee Schedule) Guidelines

Refer to General Policy Guidelines

FEP Guidelines

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

Also refer to General Policy Guidelines

Comprehensive/Wraparound/PPO Guidelines

Comprehensive

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

Also refer to General Policy Guidelines

Managed Care (HMO/POS) Guidelines

Refer to General Policy Guidelines

Publications

References

View Previous Versions

[Version 002 of G-19]
[Version 001 of G-19]

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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.