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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.
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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.