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Illinois Medical Bill Reviewer Training Program

Unit 1:Professional ServicesModule 5: Pathology and

Laboratory Services

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Overview Hello, in this module, you will learn about

Pathology and Laboratory services

and guidelines.

Pathology and Laboratory Guidelines Types of Pathology Services Reimbursement per IL Medical Fee

Schedule

We’ll start by discussing the

general guidelines, then move on to the

different types of pathology services.

Illinois Regulation Training – Path & Lab

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Pathology Guidelines

Pathology is the study of the nature and cause of disease, which involves changes in structure and function.

The Fee Schedule Pathology and Laboratory

section ranges from 80048-89356.

A pathologist is trained to examine tissues, cells, and specimens of body fluids for evidence of

disease.

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Pathology Guidelines

Compared to coding for anesthesia and surgical services, coding for pathology services is relatively simple.

Pathology services: Are fully automated. Rarely need modifiers. Are not subject to multiple

cascades. Subject to very few special

rules.

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Types of Service

There are three categories of maximum medical reimbursement for pathology and laboratory services, such as. . .

Professional

ComponentTechnical

Component

Let’s take a look…

Total Component

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Professional Components

There are certain pathology and laboratory codes that are for physician, or professional, services only.

Professional

Component

Professional services include: Examining a patient.

Conducting or supervising a procedure.

Interpreting and documenting, in a written report, the examination & consultation with the referring physician.

Designated by modifier 26

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Professional Components

When a charge is submitted for a physician’s interpretation of a test or procedure, or other professional services related to that test or procedure, as designated by modifier 26, the maximum medical reimbursement will be that listed in the “PC AMOUNT” column of the fee schedule.

Documenting interpretation of test and procedures is an integral part of the professional component.

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Technical Component

The technical component of service includes all other charges not related to the value of the physician’s services.

Technical Component

Technical services include:

Personnel (i.e. technicians) Space, equipment, and

other facilities. Designated by modifier “TC”

as listed in HCPCS Level II

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Technical Component

When a charge is submitted for only the technical component, as designated by modifier TC, the maximum medical reimbursement will be that listed in the “TC AMOUNT” column.

Technical services are generally facility related.

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Global Service

The majority of pathology and laboratory procedures include both a professional and technical component, which constitutes a global service. For instance, a procedure is considered a global service when the same provider performs both the professional and technical components.

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Global Components• When a charge is submitted by one physician who provides both the technical and professional components of a pathology or laboratory, designated with no modifier, the maximum medical reimbursement will the amount listed in the “TOTAL” column.

Remember, when there is not an established fee schedule allowable for the professional, technical or global component, service are paid at 76% of billed charge.

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Summary

Pathology and Laboratory: Professional Component. Service provided by physician – modifier 26

Pathology and Laboratory: Technical Component. Service provided by the facility – modifier ‘TC’

Pathology and Laboratory: Global ComponentPhysician preformed both PC & TC service – no modifier

Good Job! You’re a Star.