DOS Coding and Billing for Surgical and Anatomical Pathology Services
On September 19, 2017, the Centers for Medicare & Medicaid Services (CMS) released MLN Matters Number: SE17023 to provide coding and billing guidance for surgical and anatomical pathology date of service (DOS) on professional claims. However, it was immediately rescinded.
The following update references the Internet Only Manual Update to Chapter 16 (Section 40.8: Date of Service Policy effective January 1, 2018) of the Pub 100-04.
Surgical and anatomical pathology services can be split into either professional component (PC) or technical component (TC), each separately billable to the local Medicare Administrative Contractor (MAC) when not reported as a global service. The PC and TC components are reported to distinctly identify a split service performed by a physician or pathology laboratory. These services will have a PC/TC indicator of “1” on the Medicare Physician Fee Schedule (MPFS) Relative Value (RVU) File.
PC and TC do not apply to physician or other qualified healthcare professional services that cannot be distinctly split into professional and technical components. Modifiers PC and TC may not be used with such billing codes.
Differences Between PC and TC
Modifier PC (also referred to as modifier .26) is used with the appropriate CPT© code to report the supervision and interpretation portion of a diagnostic test (e.g., 88305—surgical pathology, gross and microscopic examination) and includes indirect practice and malpractice expenses related to that work.
Modifier TC appended to the appropriate CPT© code is used to report all nonphysician or qualified healthcare professional work and includes administrative, personnel and capital (equipment and facility) costs, and related malpractice expenses.
In practical terms, modifier TC is used to report the slide-preparation portion, while modifier .26 indicates the slide-reading portion.
Choosing Appropriate DOS
Generally, CMS states that the DOS of the test/service must be the date the specimen was collected. The following table explains when and how to apply the appropriate DOS. For more information about choosing appropriate DOS, visit https://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/2018Downloads/R4000CP.pdf.
| Description of Service | Appropriate Billing Date of Service (DOS) |
|---|---|
| Technical Component (TC) | Billed on the date the surgery is performed (the date the specimen was collected) |
| Professional Component (PC) | Billed on the date when the physician or qualified healthcare provider provides the interpretation and report of the pathology service |
| If PC and TC occur on different dates | Bill on different dates using the TC modifier for the technical component and modifier 26 for the professional component |
| Collection of specimen spans two calendar dates | Use the date the specimen collection ended |
| Exceptions to DOS Policy: Stored specimens (stored less than or equal* to 30 calendar days) from collection date, the date of service must be the date the test was performed, only if: |
|
| *Note: If the specimen was stored for more than 30 calendar days before testing, the specimen is considered to have been archived and the DOS of the test/service must be the date the specimen was obtained from storage. | |
Source: Medicare Claims Processing Manual. Chapter 16,Section 40.8: Date of Service (DOS) for Clinical Laboratory and Pathology Specimens.
