CMS Correcting Error in Processing of Claims by Pathologists and Independent Laboratories for Professional Component of Certain Physician Pathology Services

CMS is taking immediate action to correct an error in processing claims submitted by certain pathologists and independent clinical laboratories for the professional component (PC) of physician pathology services. Under previous law, a statutory moratorium, which expired on June 30, 2012, allowed certain practitioners and suppliers to bill a carrier or an A/B MAC for the technical component (TC) of physician pathology services furnished to hospital patients. In the file furnished to contractors used to implement the expiration of this claims payment policy, CMS erroneously included several Health Care Procedure Code System (HCPCS) codes for the PC of a physician pathology service in the list of TC HCPCS codes. As a result, some claims for the PC of a physician pathology service, when submitted by a pathologist or by an independent clinical laboratory, are being improperly denied on the basis of the expiration of this moratorium. In the case of an independent clinical laboratory, the laboratory may only be paid if a physician employed by the laboratory performed the PC of such service.

As an interim measure, CMS is instructing contractors to override the edit which is causing the improper denials of PC of physician pathology services for claims with a date of service (DOS) between July 1, 2012 and January 1, 2013. CMS is also instructing each contractor to reprocess all claims billed by pathologists or independent clinical laboratories for the PC of a physician pathology service with a DOS on and after July 1, 2012, to and through the date that the contractor begins to use the override for the edit. No further action on the part of pathologists or independent clinical laboratories will be necessary at this time.