Provider Alerts

Please review the following California Medicaid (MCL) billing guidelines for proper claim submission and reimbursement for pathology services.

Diagnosis Code Requirement: All claims for clinical laboratory tests or examinations (CPT 80000 series codes) require an ICD-10-CM diagnosis code.

Billing Method Guidelines

Clinical laboratory tests or examinations (CPT 80000 series codes) are billed using different methods. Although the method used depends on the contractual or other type of mutual agreement between the facility and the physician and will apply to both inpatient and outpatient services, the principal determinant will be the provisions of the contract the facility has with the MCP.

The Department of Health Care Services (DHCS) has defined the billing options as follows:

Split-Billable

Split-billable services: When billing for both the professional and technical service components, a modifier is neither required nor allowed. When billing for only the professional component, use modifier 26. When billing for only the technical component, use modifier TC.

• Physician Billing – Facility bills for both the technical and professional components using one line without a modifier. The facility reimburses the pathologist/pathology group for the professional component per their mutual agreements.
• Facility Billing – Physician billed for both the professional and technical components using one line without modifier. The physician subsequently reimburses the facility for the technical component according to their mutual agreements.

Note: Modifier 99 must not be billed in conjunction with modifier 26 and modifier TC. The claim will be denied.

Professional (Split Billing) Component Restrictions

Emergency room physicians, orthopedic surgeons, trauma specialists, surgeons, internists, family physicians, podiatrists and other treating physicians who routinely review pathology results as an integral part of their reimbursed patient care services are not entitled to an additional reimbursement of a professional component for that review. This service, like other diagnostic data evaluations, is covered by reimbursement for office visits and treatment.

Modifier 26

Providers are not reimbursed for the professional component (modifier 26) of pathology claims billed with an Evaluation and Management (E&M) procedure performed by the same provider on the same date of service. Providers are not reimbursed for the professional component when billing for both the professional and technical service components when pathology services are billed with an E&M procedure performed by the same provider on the same date of service.

Not Split-Billable

Services that are not split-billable: These codes are not separately reimbursable to different providers for a professional or technical component.  Only one provider may bill for these codes.  These codes must not be submitted with modifier 26, TC, or 99 and do not require a modifier.

For additional guidance and list of CPT Codes Not Split-Billable, please see: https://mcweb.apps.prd.cammis.medi-cal.ca.gov/assets/6111CBD6-6671-41AF-921F-3EB993362756/pathbil.pdf?access_token=6UyVkRRfByXTZEWIh8j8QaYylPyP5ULO

If you have any further questions, please contact your Provider Services Representative, or call our Customer Service Department at 1-888-936-PLAN (7526). You may also visit https://www.hpsj.com/alerts/ for online access to the documents shared. The most recent information about Health Plan and our services is always available on our website WWW.HPSJ-MVHP.ORG