What Is Pathology Billing?

Pathology billing is one of the most complex and vital medical billing processes, crucial to maintaining the financial stability of healthcare organizations. Ensuring accurate billing guarantees that healthcare providers are properly compensated for their services. As a provider of pathology billing services, we understand the challenges this process presents and the importance of optimizing it for maximum efficiency and increased cash flow. But what exactly is pathology billing, and how can it be optimized for better outcomes?

In this article, we will delve into the definition and usage of this specialized billing practice, highlighting its importance and key components. We will also offer insights into best practices for optimizing pathology billing to help you improve revenue streams and streamline operations.

What Is Pathology Billing?

Pathology billing involves submitting claims to insurance companies for reimbursements for pathology services. This includes any diagnostic services pathology specialists provide and tests run in pathology laboratories. Since this specialty focuses on various tests and diagnostic procedures based on examining tissues, cells, and bodily fluids, it has a specific set of codes to document your services properly.

Pathology has three specific types of services that can be billed. This includes clinical, anatomic, and molecular pathology, each with its own specific characteristics. 

While clinical pathology focuses on bodily fluids such as blood and urine, anatomic pathology revolves around tissues and cells. As for molecular pathology, this practice specializes in advanced molecular techniques, such as genetic testing and DNA analysis.

Key Components of Pathology Billing

As with most specialties, pathology billing is based on a unique set of ICD and CPT codes. We’ll explain each one separately to better understand its use and importance.

CPT coding for pathology services

CPT codes, also known as Current Procedural Terminology codes, describe diagnostic, medical, and surgical services and indicate the rates of each service for reimbursement. The AMA (American Medical Association) established the coding system, which has specific codes designated for pathology services, commonly ranging from 80047 to 89398. 

They include pathology procedures and clinical laboratory testing since they are utilized to calculate the fees for your services. Some of the most common CPT codes for pathology billing are the following:

• 80305 – 80377: Drug Assay Procedures (used to assess or measure the presence, amount, or functional activity of a specific drug).
• 80503 – 80506: Clinical Pathology Consultations (a pathology consultation that includes a written report).
• 81105 – 81479: Molecular Pathology Procedures (the use of advanced molecular techniques, including genetic testing and DNA analysis).
• 81000 – 81099: Urinalysis Procedures (different types of urine testing).
• 88300 – 88399: Surgical Pathology Procedures.

ICD coding in pathology billing

ICD stands for International Classification of Diseases codes and describes the patient’s diagnoses and reason for medical treatment. The World Health Organization (WHO) developed and maintains this coding system. When used for pathology billing, it can change based on the patient’s condition. Some of the most common ICD-10 codes used in pathology are the following:

• R00 – R99: Symptoms, signs, and abnormal clinical and laboratory findings not elsewhere classified.
• A00 – B99: Certain infectious and parasitic diseases.
• C00 – D49: Neoplasms.
• L00 – L99: Diseases of the skin and subcutaneous tissue.

Optimizing Revenue in Pathology Billing

The main challenge faced with medical billing is facing a claim denial. When this happens, the insurance payer refuses to pay for the services you’ve provided due to not meeting the billing guidelines and standards.

However, you can take a few simple measures to ensure timely reimbursement and prevent delays in your revenue cycle. Here are the ones that have the greatest impact on your revenue generation:

• Efficient coding: Regardless of the specialty, billing requires efficient coding and staying up to date with the latest coding changes. Since the CPT and ICD-10 are the main components of pathology billing, you should always assign the proper codes to the diagnosis, specimens, and related testing.
• Accurate documentation: Pathology billing requires rigorous documentation and attention to detail. Always double-check that the information in your documentation matches the assigned codes and fully explains the service and treatment.
• Timely claim submission: Insurance payers have strict deadlines for submitting claims. So, using proper billing operations to track upcoming deadlines can prevent unwanted denials. 

Best Practices for Pathology Billing

With the experience we’ve gathered throughout the years, we also want to highlight some of the best practices regarding pathology billing. Even though many healthcare organizations often overlook their importance, some of the key factors in this type of medical billing are the following:

• Documentation excellence
• Coding accuracy
• Claims submission and denial management

Documentation excellence

As mentioned, pathology billing requires thorough documentation and has specific requirements that must be followed. Ensuring thorough documentation helps prove the medical necessity of the services provided, reducing the risk of claim denials due to insufficient evidence. Here are some of the key documentation requirements for pathology billing you should know:

• Specimen descriptions: Each specimen must be clearly labeled with the patient’s information and include details such as the type of specimen, collection date, time, site, and the name of the healthcare provider collecting the specimen.
• Test results: When documenting test results, you should always include the raw data, units of measurement, normal reference ranges, and the physician’s interpretation.
• Clinical indications: Record all the symptoms, signs, and diagnoses that justify the need for the pathology test.

You can use standardized templates and forms with fields for all the essential information to ensure your documentation meets the required standards. This practice allows consistency throughout the billing process and minimizes the chances of missing crucial information.

Coding accuracy

You should always stay up-to-date with the latest coding regulations to ensure proper coding accuracy. If you’ve already taken the time to gather proper documentation, you should always cross-check the codes with the corresponding diagnosis, treatments, and services. 

Many healthcare organizations use EHR (electronic health records) systems and coding software to simplify this process. Most of these tools suggest codes based on the documentation you’ve already added to the software.

Another way to improve your coding accuracy is to provide continuous training and education to your medical and billing staff. This will keep them updated on the latest documentation requirements, coding changes, and best practices.

Claims submission and denial management

You may still receive the most common claim denials even after optimizing your pathology billing process. If you don’t take the necessary measures to combat the denial, this can cause a distribution within your revenue cycle and lead to revenue loss. 

You must have a proper denial management system to promptly identify and correct your claims. Billing software can help you accurately track and monitor denials by giving you real-time information about the denial reasons and the payer behind the denial. 

Furthermore, you’ll be able to categorize the denials and analyze them to discover their root cause, allowing you to implement the proper measures to prevent them in the future. By addressing the issues within the claim quickly, you’ll also ensure a timely denial appeal, increasing your chances of getting reimbursed for the services you’ve offered. 

Regulatory Compliance in Pathology Billing

Ensure regulatory compliance is another important element you should know before optimizing your pathology billing. As mentioned, medical billing is subjected to rigorous safety and privacy standards due to its access to private patient data. 

So, you need to stay up-to-date with the latest regulatory changes commonly defined by the Centers for Medicare and Medicaid Services and other accrediting bodies. That being said, some of the most important pathology billing regulations you should familiarize yourself with are the following:

• CAP (College of American Pathologists): The CAP Laboratory Accreditation Program has defined specific lab regulations and standards regarding quality control and assurance. These include personnel qualifications and competency, laboratory safety and equipment, proficiency testing, and specimen handling and processing.
• NCCI (National Correct Coding Initiative): A set of practices that prevent inaccurate payment caused by improper coding when specific codes are submitted together.
• TJC (The Joint Commission): For pathology billing, the TJC has accreditation standards regarding quality improvement in laboratory services and patient safety. Their main goal is to ensure healthcare organizations can easily measure, assess, and improve their performance.
• HIPAA (Health Insurance Portability and Accountability Act): Data protection measures that ensure the confidentiality and security of patient data. 

Outsourcing Solutions for Pathology Billing

As the process is considered to be one of the most complex aspects of running a healthcare organization, many turn to specialized outsourcing providers to optimize their billing efforts and ensure higher reimbursement rates. Since the main focus of any medical facility should be delivering quality patient care, you can take the workload off your healthcare providers’ shoulders and reduce your overall administrative workload.

That’s why our team at CLICKVISION BPO has medical billing services specializing in many industries ready to optimize your medical billing based on the latest practices. By working alongside our trained professionals, you can improve your revenue cycle management and reduce the costs associated with staff training. You will avoid potential errors that may disrupt your revenue cycle and be able to focus on more important matters related to patient care. 

Conclusion

So, what is pathology billing, and how can you optimize it to generate more revenue? After reviewing the basics and use of pathology billing, remember that proper documentation, coding, and timely claim submissions are essential in ensuring timely reimbursement. Even though you may be met with a denial, having a proper denial management system will help you implement the needed changes without risking not getting paid. 

Remember, if you ever struggle with improving your billing process, you can always contact our team at CLICKVISION BPO for access to trained professionals, advanced software, and the latest practices.