Specialty
Pathology billing services
Pathology billing services cover the physician's read of tissue and cells, and every claim turns on who did which part.
See where claims are getting stuck. No patient data needed.
The pathologist bills the professional component with modifier 26 when a hospital or another lab prepared the slides, bills globally only when one entity did both parts at one location, and counts units the way NCCI defines them: by specimen for surgical pathology and frozen sections, by stain and block for special stains, by antibody and specimen for immunohistochemistry. Remitwright gives pathology groups a dedicated biller who sets each case's component and units from the report and works denials back to the cause.
Pathology billing is one of Remitwright's specialty billing services, each set out with its own code families, denial reasons and payer rules.
Last reviewed by the Remitwright billing team. Editorial policy
- 80500
- 88104-88112
- 88187-88189
Denials
Why pathology claims get denied
The reasons that come up most on pathology remittances, with the usual cause and the fix. Code explanations are our own; the official list is maintained by X12.
| Code | Reason | Usual cause | The fix |
|---|---|---|---|
| CO-171 | Slide work billed for a hospital patient | An independent lab billed the technical or global code for a specimen from a hospital inpatient or outpatient, whose slide work the hospital's payment already covers | Patient status read from the requisition, with the pathologist's read billed with 26 and the slide work left with the hospital |
| CO-B20 | Part of the work came from elsewhere | A global code billed for a case whose slides a hospital or reference lab prepared and billed for itself | Component set by who prepared the slides and who read them, with the global code kept for cases done entirely in house at one location |
| CO-151 | Units above what the case supports | Immunohistochemistry billed per block instead of per specimen, recut levels counted as extra stains, or prostate cores billed as 88305 units | Units counted from the gross description and the stain log, with G0416 for prostate needle biopsies |
| CO-97 | Paid as part of another code | 88300 billed with a higher level for one specimen, stains billed with a second opinion on slides another pathologist already read, or flow cell counts billed with the interpretation | NCCI pairs checked specimen by specimen before release |
| CO-50 | Second method or routine call billed | Immunohistochemistry and flow cytometry both billed on similar specimens with no note on why the first method fell short, or a results phone call billed as a clinical consultation | The reason for a second method written into the report, and 80500 or 80502 billed only when all four Medicare conditions are in the record |
| CO-4 | Modifier does not fit the code | A clinical lab interpretation sent without 26, or the technical part of a physician-read hybridization code billed when a technologist read the probe | Code and modifier chosen together from the report's signature and the test type |
Codes
Common pathology codes and modifiers
Code families by number with our own one-line explanations. CPT descriptors belong to the AMA and are not reproduced here.
| Codes | What the family covers |
|---|---|
| 80500, 80502 | Clinical pathology consultation, professional only, payable when the attending physician asks for it about an abnormal result and the pathologist answers with judgment in a written narrative report. |
| 88104-88112, 88172, 88177 | Cytology of fluids, washings and brushings, and the on-site adequacy check of a fine needle aspirate, which is counted by evaluation episode rather than by needle pass. |
| 88187-88189 | Flow cytometry interpretation: one code covers every marker read on a specimen, and cell counts done by flow are not billed with it. |
| 88300-88309 | Surgical pathology by level, from a specimen examined by eye alone (88300) up to the most involved gross and microscopic work. The unit is the specimen: tissue sent for its own examination and diagnosis, usually in its own container. |
| 88312-88319 | Special stains, one unit for each stain on each block. Extra levels cut from one block and stained again, and the control slides, add nothing. |
| 88321-88325 | A second opinion on slides or material prepared and read at another location, one unit per case whatever the slide count. Pathologists in the same group cannot bill it for each other. |
| 88329-88334 | Consultation during surgery, including frozen sections, with the base codes counted per specimen. The gross look is part of the service, so 88300 is never added for the same specimen. |
| 88341, 88342, 88344, 88360, 88361 | Immunohistochemistry, one unit per antibody procedure per specimen however many blocks were stained, with 88360 for manual quantitative work and 88361 when computer-assisted imaging does the counting. |
| 88364-88377 | In situ hybridization read and interpreted by a physician, billed globally or with 26. When a technologist reads the probe instead, the lab reports 88271-88275 and not these codes. |
| G0416 | Every prostate needle biopsy specimen from one patient, reported as a single unit in place of 88305 units. |
Modifiers that matter
- 26
- The pathologist's read when a hospital or another lab prepared the slides. It also goes on the clinical lab interpretations Medicare lists for separate physician payment.
- TC
- The slide preparation, billed by the lab that did it for a patient who is not a hospital inpatient or outpatient. For hospital patients the hospital's own payment covers it.
- 59 or XS
- Separate cytology specimens from different anatomic sites, each documented in the report, so related codes from the same group can be billed for each site.
- 59 or XU
- Immunohistochemistry and flow cytometry on the same or similar specimens, used only when the first method left the microscopic findings unexplained and the report says so.
Pathology billing is not clinical laboratory billing
A clinical laboratory bills tests: the analyzer run, the CLIA certificate behind it, the panel and the lab fee schedule. Pathology bills a physician's judgment on tissue and cells under the physician fee schedule, so the questions change: who prepared the slides, who read them, how many specimens the surgeon sent and whether a second method was needed.
When one organization does both, the two claims are built separately. The test side, with CLIA numbers, waived tests and reference lab work, is on the clinical laboratory billing services page, and this page covers the professional read.1
Payers
Payer notes
- MedicareFor services on or after July 1, 2012, an independent lab cannot bill the A/B MAC for the technical component of a physician pathology service furnished to a hospital inpatient or outpatient. The professional component can still be paid under the physician fee schedule.1
- MedicareGlobal billing of a service split into professional and technical parts is allowed only when the same physician or supplier entity furnished both. If the two parts were done at different enrolled practice locations they are billed separately, and putting the same place of service code on both does not change that.1
- MedicareA clinical consultation is paid only when the attending physician requests it, it concerns a result outside the clinically expected range, it ends in a written narrative report in the chart and it calls for medical judgment. Routine calls between the lab director and the attending physician about orders or results do not qualify.1
- MedicarePayment for a physician's reading of a Pap smear, reported as P3000 or P3001, depends on two things: the lab's screening staff suspected an abnormality, and the physician personally reviewed and interpreted the smear.1
- Medicare and NCCISeparate specimens must be medically reasonable to submit for their own examination. NCCI's example is two polyps found at different depths in one colonoscopy, which may go as two specimens, while several biopsies of one polyp usually go as one.2
- Medicare and NCCIMedicare does not pay for duplicate testing. If one method establishes the diagnosis on one specimen, the same or another method is not billed on a similar specimen, such as blood and bone marrow, a marrow aspirate and biopsy, or two separate lymph nodes.2
- MedicareThe date of service for the technical component of a pathology service is the date the specimen was collected, or the date collection ended if it spanned two days. A specimen stored more than 30 days before testing counts as archived, and its date is the day it came out of storage.3
Authorizations
Surgical pathology seldom needs its own authorization, because the pathologist does not order the case: a surgeon or clinic sends the specimen, and any approval sits with the procedure that produced it. Approval questions come up with molecular and genetic testing, which Medicare Advantage and commercial plans may review before the test runs. Your biller confirms the ordering physician, the patient's status and the coverage from the requisition, and checks plan policy before any test a plan lists for review.
Documentation traps
- A gross description that lumps tissue from several containers together, so separate specimens cannot be defended
- Stain and antibody logs that do not tie each stain to a block and a specimen
- No sentence in the report on why a second method was run after the first one did not explain the findings
- A clinical consultation with no request from the attending physician and no narrative report in the chart
- A requisition missing the patient's status or the collection date, which decide who bills the slide work and on what date
What a specialist checks
Specialist or generalist for pathology billing?
A generalist biller can enter a pathology claim. Whether it pays turns on three things specific to pathology billing, and a specialty-aware biller checks each one.
Code families
Each family billed with what the chart has to show for it.
- 80500, 80502
- 88104-88112, 88172, 88177
- 88187-88189
Modifiers
Applied only where the note supports them, line by line.
- 26
- TC
- 59 or XS
Denials
The usual causes checked before the claim goes out, and any denial traced back to the chart or the claim.
- CO-171
- CO-B20
- CO-151
If you are moving from another billing company or an in-house biller, switching billing companies follows a plan: the old and new processes run side by side until the new one is proven, and every login and every pathology claim stays in your name.
What we handle
What we handle for pathology practices
- Medical codingCPT, ICD-10 and modifiers assigned correctly
- Charge entryEvery encounter captured, nothing left unbilled
- Claim submissionScrubbed, submitted and tracked to acceptance
- Medicare billingPart B claims, MSP, ABNs and appeals
- Denial managementEvery denial read, worked and appealed
- Payment postingERAs and EOBs posted, variances flagged
A dedicated biller with named cover, working inside your system and reporting to you on one written page. How it works sets out the five stages.
Worked example: the hospital biopsy billed globally
A pathology group that also runs an independent lab receives a breast biopsy from a hospital outpatient department. Its lab cuts and stains the slides, and its pathologist signs the report. The claim goes to Medicare as a global 88305 with two immunohistochemistry stains, and the technical portion is denied because the patient was a hospital outpatient.
The biller reads the requisition, rebills the surgical pathology and both stains with modifier 26 for the pathologist's read, and routes the slide work to the hospital under the agreement between the lab and the hospital. Intake now records the patient's status before any case is coded.
Software
Systems pathology practices usually run
Your biller works inside your system as a user you create. All the systems we work in.
Questions
Questions about pathology billing
When does a pathologist bill 26 instead of the global code?
How are specimens counted for 88305?
How many units of immunohistochemistry can we bill?
Can we bill a second opinion on outside slides?
When can we bill a clinical pathology consultation?
What date of service goes on the technical component?
Is pathology billing the same as clinical laboratory billing?
What does a pathology group provide so billing can start?
Next step
See where your pathology claims are getting stuck.
Three quick questions. No patient data. A billing specialist reads every request and replies in writing.
- Three questions, about two minutes
- No patient data, no software to buy
- A written reply from a biller, not a sales deck
You answer three questions
A billing specialist reads them
A written reply by email
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- A billing specialist reads your answers and replies by email.
- If a look at real claims makes sense, we agree read-only access under a BAA first.
- You get a written summary of what is worth working and what it would take. No commitment.
While you wait: see the sample weekly report or read how switching works. You can also download the sample weekly report (PDF).