Highmark Medical Policy Bulletin
Section: Miscellaneous
Number: G-19
Topic: Professional Component for Pathology Tests
Effective Date: January 1, 2005
Issued Date: January 3, 2005
Date Last Reviewed: 10/2003

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):

0058T
0059T
85097
85396
88000-88099
88104-88199
88230-88299
88300-88399
89254-89257
89260-89261
89300-89325
89335-89356
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
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

0058T0059T82131824868302083912
841658418184182849998506085097
853908539685576860778607886079
862558625686320863258632786334
863358716487207880008800588007
880128801488016880208802588027
880288802988036880378804088045
880998810488106881078810888112
881258813088140881428814388144
881458814788148881508815288153
881548815588160881618816288164
881658816688167881708817188172
881738818288184881858818788188
881898819988230882338823588237
882398824088241882458824888249
882618826288263882648826788269
882718827288273882748827588280
882838828588289882918829988300
883028830488305883078830988311
883128831388314883188831988321
883238832588329883318833288342
883468834788348883498835588356
883588836088361883628836588367
883688837188372883998906089254
892558925789260892618930089310
893208932189325893358934289343
893448934689352893538935489356
G0123G0124G0141G0143G0144G0145
G0147G0148P3000P3001  

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 / 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

Publications

References

View Previous Versions

[Version 005 of G-19]
[Version 004 of G-19]
[Version 003 of G-19]
[Version 002 of G-19]
[Version 001 of G-19]

Table Attachment

Text Attachment

Procedure Code Attachment


Glossary




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.