Pathology Billing Guidelines

Since the healthcare industry is responsible for real-life patient information and care, it must follow some of the most complex regulatory guidelines and practices. These rules and regulations are set in place to protect the patient’s private data and ensure their safety. That’s why, in this article, we’ll elaborate on the most important pathology billing guidelines and their meaning.

By explaining the most important regulations regarding this specialty, we want to aid healthcare organizations in optimizing their overall business operations. Besides, following these guidelines ensures legal operation and financial stability while providing high-quality patient care. Failing to comply with the regulations can result in delayed reimbursements and legal repercussions.

Regulatory Framework

The first element of the pathology billing guidelines we want to focus on is the regulatory framework. Since any healthcare practice is responsible for the safety and well-being of patients and their data, there are various federal and state regulations set in place to ensure compliance, accuracy, and transparency during the process. The ones that have the biggest importance for your healthcare organization’s legal operation are the following:

• HIPAA
• Stark Law
• AKS
• CLIA

HIPAA

Short for the Health Insurance Portability and Accountability Act, these regulations are set in place to protect the patient’s health information, whether they’re in paper or electronic form. So, healthcare organizations are required to adopt specific measures for handling personal records, billing records, electronic healthcare transactions, and claim submissions.

Stark Law

Also known as the Physician Self-Referral Law, this regulation prohibits physicians from referring DHS (designated health services) to patients if they have a financial relationship with the entity, especially if the laboratory services are payable by Medicare or Medicaid.

AKS

Short for Anti-Kickback Statute, this criminal and federal law prohibits healthcare organizations from offering or receiving financial payments when referring patients for services that may otherwise be reimbursable by federal healthcare programs.

CLIA

Also known as Clinical Laboratory Improvement Amendments, these federal regulatory standards are set in place to protect patients during clinical laboratory testing. Even though they’re not applicable during basic research and clinical trials, healthcare organizations must oblige specific quality control, personnel qualifications, and proficiency testing requirements. 

Coding Guidelines

In addition to the regulatory frameworks, you should familiarize yourself with the coding guidelines to prevent potential claim denials. Healthcare organizations are required to document their services using standardized medical coding systems to get properly reimbursed. These medical billing codes describe the patient’s diagnosis, treatment, procedures, and the supplies used during their visit.

To ensure compliance with the coding guidelines, you should familiarize yourself with the following coding systems:

• CPT
• ICD-10
• HCPCS
• Modifiers

CPT

Short for Current Procedural Terminology codes, this system was introduced by the AMA (American Medical Association) and is used to describe diagnostic, medical, and surgical services. For pathology billing, these codes range from 80047 to 89398 and include both clinical laboratory tests and pathology services and are used to determine the charges for the services provided. 

ICD-10

ICD-10 is short for the tenth revision of the International Classification of Diseases codes, and the system was set in place and is maintained by the WHO (World Health Organization). Unlike the CPT codes, the ICD-10 system is used to describe the patient’s diagnoses and reasons for medical treatments. In pathology, these codes vary depending on the patient’s condition. 

For example, certain infectious and parasitic diseases are explained with codes ranging from A00 to B99, while symptoms and abnormal clinical and laboratory findings not elsewhere classified are documented with codes ranging from R00 to R99.

HCPCS

Also known as the Healthcare Common Procedure Coding System, HCPCS codes were developed by the CMS (Centers for Medicare and Medicaid Services). They’re mostly used when billing for services covered by Medicare and Medicaid and are used to describe procedures and equipment not covered by the previously mentioned CPT codes. 

To properly segment these codes, the level I HCPCS option focuses on medical services and procedures, while the level II HCPCS codes cover products, supplies, and services not included in CPT codes. The second level can also include certain drugs and other medical equipment. 

Modifiers

You should always use the proper modifiers to provide additional information about the services you’ve provided when necessary. These coding elements can also be used to indicate that a certain service or procedure has been altered without changing its primary code. 

When it comes to pathology modifiers, some of the most common examples are the following:

• Modifier 26: Commonly defined as a PC (professional component), this modifier is used to describe that the service provided has included technician supervision, interpretation of results, or a written report.
• Modifier TC: Defined as a technical component, this modifier is used when the service you’ve provided has both a professional and technical aspect. For example, it occurs when describing the performance of a specific test, but the physician hasn’t interpreted it. 
• Modifier 59: Used to describe a distinct procedural service and occurs when a healthcare provider needs to distinguish two separate procedures provided on the same date of service. 

Documentation Requirements

As with any healthcare specialty, pathology billing has specialized documentation requirements you should include during the billing process. Documenting each aspect of patient care ensures that healthcare providers can appoint the appropriate codes during the billing process. Furthermore, gathering sufficient paperwork and documentation is used to prove the medical necessity of the services provided, preventing potential claim denials based on lack of medical necessity. 

That being said, some of the most important documentation requirements regarding pathology billing are the following:

• Specimen descriptions: If the patient care involves specimen collection, each of the collected specimens must be labeled with the patient’s information and identification. Furthermore, you’re required to document any collection details, such as the time and date of collection, the name of the provider taking the specimen, the specimen collection site, and the type of specimen. 
• Test results: Pathology billing requires detailed documentation of any pathology tests and their results. This includes the raw data, normal reference ranges, units of measurement, physician interpretation, and any further analysis that may have been required. 
• Clinical indications: You should document all the symptoms, signs, and diagnoses to justify the necessity of the pathology test.

Compliance Standards

Another important factor within the pathology billing guidelines is the compliance standards. Some of the most common regulations are defined by the Centers for Medicare and Medicaid Services and other accrediting bodies. Here are some of the standards you should familiarize yourself with to ensure proper pathology billing:

• NCCI: Short for National Correct Coding Initiative, these edits are set in place to prevent improper coding when certain codes are submitted together, which may result in inaccurate payment. 
• CAP (College of American Pathologists): Pathology practices must adhere to specific lab regulations and standards as noted in the CAP Laboratory Accreditation Program. This includes proper quality control and assurance, personnel qualifications and competency, proficiency testing, laboratory safety and equipment, and specimen handling and processing. 
• TJC (The Joint Commission): These accreditation standards are set to ensure healthcare organizations can easily measure, assess, and improve their performance. For pathology, the TJC is focused on patient safety and quality improvement regarding laboratory services.

The best way to ensure compliance with these standards is to frequently monitor regulatory changes and develop a compliance program. This will allow you to utilize the appropriate technology and automation while also providing proper training and education for your medical personnel. 

Reimbursement Policies

You should familiarize yourself with each insurance company’s unique reimbursement policies. These policies ensure proper pathology billing and payments per payer guidelines. Since insurance providers such as Medicare, Medicaid, and other private insurers are prone to frequent policy changes, healthcare organizations must stay up-to-date and alert for when they appear. 

Even though each insurance company has its unique reimbursement policies, some of the key elements that recur are the following:

• Fee schedules and allowable charges: Insurance companies often have predetermined reimbursement fees and allowable charges on which they base their payment. So, it’s best if you familiarize yourself with their offers beforehand.
• Preauthorization and precertification: Some insurance providers may ask for preauthorization regarding specific pathology services you want to offer. That’s why, you should obtain all the necessary precertification from the designated payer before any procedures or treatments are applied. 
• Timely filing: One of the most important aspects you should focus on is the timely filing of claim submissions. Each insurance company has a specified timeframe within which you can submit your claim. Failing to adhere to these deadlines can result in claim denials and delays in reimbursement. 

Billing Practices

Now that you’re well-informed about some of the most important pathology billing guidelines, we also want to highlight some of the best practices you can implement within your business operations. To ensure proper reimbursement and prevent potential revenue loss, here are some elements of the billing process you should focus on:

• Timely claims submission: Always ensure you’ve prepared, reviewed, and sent the claim within the insurance company’s given deadlines. 
• Accurate charge capture: While many healthcare organizations overlook the importance of proper documentation, it’s essential to start gathering evidence and information about the services you offer as soon as the patient walks in for their appointment. Including all the clinical records and physician notes will ensure accurate charge capture and lower the risks of denials due to missing information and lack of medical necessity.
• Denial management: Even though you may have optimized your pathology billing process, implementing the proper denial management strategy is a must. By utilizing proficient technology and tactics to quickly identify, analyze, and correct the errors that may have led to the denial will ensure timely denial appeals and improve your reimbursement chances. 

Outsourcing Solution

Many healthcare organizations overlook the importance of optimizing their medical billing process because they want to focus their effort on enhancing their patient care. Since pathology billing requires continuous monitoring and improvements, medical facilities are often disheartened by the costs of implementing proper staff training and utilizing advanced billing software.

So, they often turn to outsourcing services as a cost-effective way of accessing billing specialists. Outsourcing companies, like CLICKVISIONBPO,  specializing in the healthcare and insurance sectors, have trained professionals with expertise in the specific fields you’re interested in. 

Moreover, using our pathology billing services will reduce your administrative workload, allowing you to focus on delivering higher-quality patient care.

Conclusion

After elaborating on the most important pathology billing guidelines, remember to always follow them to ensure proper reimbursement and regulatory compliance. Since this type of medical billing requires familiarizing yourself with regulatory frameworks, coding guidelines, and reimbursement policies, many healthcare organizations struggle with managing these complex operations. 

That’s why our team at CLICKVISION BPO offers tailored medical billing outsourcing services ready to meet the diverse needs of healthcare organizations. We fully understand that healthcare organizations want to focus their attention on improving their patient care, so we want to help optimize their business operations and reduce the burden on healthcare providers. By offering tailored medical billing solutions based on your unique circumstances, we aim to streamline your revenue cycle and ensure accurate, fast, and efficient billing operations. Contact us today and discover how our outsourcing services can help your healthcare organization achieve its full potential!