Pathology Date of Service Confusion
Last Updated: 12/12/2018
On September 19, 2017, CMS issued a bulletin (SE17023) clarifying the date of service for billing claims for clinical lab and pathology specimens. That bulletin had stated that when billing for pathology, the technical component was billed on the date the specimen was obtained (surgery date) and the professional component was billed on the date the pathology was read or interpreted (report date). The bulletin clarified that if these (i.e., technical and professional components) occurred on different days, they were to be billed for separately. This created quite a bit of panic for providers with in-house labs that billed globally.
On October 2, 2017, CMS rescinded that bulletin indicating it would be re-issued at a later date.
First a little history…
In November 2001, CMS adopted a general rule that stated when billing for pathology, the date of service is the date the specimen was obtained (surgery date). This was interpreted to mean that the surgery date was billed for either the technical or professional components or if the pathology was billed globally.
Approximately three years ago, that verbiage was removed, and only language regarding the date of service billing of technical components remained in national CMS policy.
The DOS policy as currently specified in 42 CFR § 414.510 (IOM, 100.04, Chapter 16, Section 40.8) for either a clinical laboratory test or the technical component of physician pathology service is as follows:
Note: No guidance for the date of service for the “professional component” is provided.
This gave Medicare contractors the opportunity to create their own rules. Some followed the old national CMS policy (i.e., DOS for TC or 26 = date specimen was obtained), and some created the rule where TC = date obtained and 26 = date slide was read.
What’s the correct way as of today?
Bulletin SE17023 attempted to create a new National policy, but was rescinded for an unknown reason (perhaps backlash from pathologists).
At any rate, the rules for date of service still fall back to Medicare Contractor preference.
Example policy from Novitas:
“The technical component is billed on the date the specimen was collected. This would be the surgery date. The professional component is billed on the date of service the physician provided the interpretation and report of the pathology service. If these occur on different dates, these must be billed with different dates of service, and modifier TC for the technical component and the modifier 26 for the professional component.
Medicare Carrier summary for pathology DOS
McKesson published an article (now removed) on their website discussing the variances of the various Medicare contractors on their pathology DOS requirements. The chart below summarizes the rules by Medicare contractor and state.
Currently National Government Services (NGS) which services CT, Washing DC, MD, NJ, PA, IL, MI, WI, and some parts of VA allow the professional component to be billed on either date (read or interpreted)
Most of the other carriers base it on date of interpretation, requiring claims to be split (i.e., no global billing)
A few other carriers (Noridian, First Coast Services, and Cahaba) currently do not have any clear policy on which date to use.