Tips on Pathology Billing & Coding

Pathology is a branch of medicine dealing with the anatomical or clinical examination of organs, tissues and cells. It is typically practiced within a laboratory setting. Various lab procedures -- including biopsies, pap smears and blood tests -- each have specific associated billing codes to supply providers with accurate payments through private and government insurance programs.

Terms of Health Insurance Plans

• Pathology health care coverage is determined mainly by the patient's insurance plan. The insurance plan will state which services are available to patients. The job of the billing department is to ascertain the level of services that are allowable by insurance coverage. Patients should be given the option for services and should be told when tests are recommended that are not covered by their insurance.

Pathology Codes

• Current Procedural Terminology (CPT) pathology codes consist of a set of five unique numbers that identify a particular service. CPT codes for both clinical and anatomical pathology services start with the number 8. Numbers between 88000 and 88399 specify anatomical pathology codes. Codes between 88300 and 88332 are commonly used by dermatologists and refer to surgical pathology procedures such as microscopic examination of excised tissues.

Variability of Medicare Fees

• While Medicare is a national insurance program, Medicare fees for anatomical pathology differ widely across the country. Some less-populated states, such as Wyoming and Nevada, use CPT codes that cover services anywhere in the state. States with more residents have CPT codes for specific areas. For instance, California has eight billing codes across the state, and the Boston metro area uses a different fee structure than the rest of Massachusetts.

Small Rural Hospitals

• Many small rural hospitals that have fewer than 50 patient beds are allowed by law to continue to receive reasonable cost reimbursements for clinical lab tests.

  President Obama signed the Patient Protection and Affordable Care Act (PPACA) into law on March 23. This act reinstates reasonable cost payments for clinical pathology lab services performed at rural hospitals where the number of patient beds is less than 50. For insurance and cost reporting purposes, it treats these services as outpatient services.