Anthem BCBS Adopts CMS Rules for Clinical Pathology Billing

February 16, 2016

  • Anthem BCBS takes a cue from CMS regarding payments for clinical pathology
  • New rules look at modifier and place of service, essentially cutting payments
  • Billing for anatomic pathology is unchanged
  • The states of Indiana, Kentucky, Missouri, Ohio and Wisconsin are affected

Anthem Blue Cross and Blue Shield of Indiana, Kentucky, Missouri, Ohio and Wisconsin has adopted CMS rules concerning billing for the professional component of clinical pathology.

This policy puts into place edits that pay or deny a claim based on the modifier and the place of service.

Billing for anatomic pathology will not change, but any payment being made for clinical pathology will be subject to the new rules.

Essentially the policy looks like it stems directly from the Medicare guidelines, which is why clinical pathology is so greatly affected, as Medicare does not pay the professional component for CP.

According to  Anthem’s Network Update:

When CMS National Physician Fee Schedule Relative Value File (NPFSRVF) designates that modifier 26 is applicable to a procedure code (PC/TC indicator of 1 or 6), and the procedure (e.g., laboratory) has been reported by a professional provider with a facility place of service, the procedure code must be reported with modifier 26 or it will not be eligible for reimbursement.

When the NPFSRVF designates that the concept of a separate professional and technical component does not apply to a laboratory procedure (PC/TC indicator of 3 or 9), and a professional provider has reported the laboratory procedure code with a modifier 26, the laboratory procedure code will not be eligible for reimbursement. When a laboratory procedure with a PC/TC indicator of 3 or 9 is reported by a professional provider with a facility place of service, the laboratory procedure code will not be eligible for reimbursement since, in this case, the facility will bill for performing the laboratory procedure.

When a professional provider bills the global code (no modifiers) with a facility place of service, the code will not be eligible for reimbursement.

When one provider reports a global procedure and a different provider reports the same procedure with a professional component (26) or a technical component (TC) modifier, only the first charge processed as approved by the Health Plan will be eligible for reimbursement and the subsequent charge processed will not be eligible for separate reimbursement.

In short, it is well known that Anthem Blue Cross and Blue Shield has tried hard to cut payments for clinical pathology, and these adaptations make their stance much stronger.

If you have questions you can contact Mick Raich at Vachette Pathology, 517-486-4262 or at mraich@vachettepathology.com.

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