PATHOLOGY AND LABORATORY GROUND RULES

 SEROLOGY: All serological procedures must be performed by registered pathologists or laboratories. 

 MATERIALS SUPPLIED BY HEALTH CARE PROVIDER: Supplies and material provided by the health care provider (e.g., sterile trays, drugs) over and above those usually included with the office visit or other services rendered may be listed separately. The statement of charges will need to list individually any drugs, trays, supplies, and materials that were provided. Payment shall not exceed the cost of the item(s) to the health care provider plus 25%, or the cost of the item(s) plus $15.00 per item, whichever is less. Use procedure code 99070. 

MAXIMUM FEES: The Maximum Fees specified herein apply to laboratories owned or operated by a health care provider, hospital laboratories, and commercial laboratories, but only when the services or procedures are performed by or under the responsible supervision of a health care provider. When a health care provider is hospital based and is not salaried or otherwise compensated for the services listed in this section, a separate bill can be rendered for the particular service. The charge is to be 60% of the Maximum Fee. 

The Maximum Fees specified herein include both the "professional" component and the "technical" component. Identification of a service or procedure by its five-digit code, without pertinent modifiers, indicates that the charge includes both the professional and technical components. Where the maximum fee is “0” for either the professional component or the technical component there is no designated payment allowed. 

The professional component includes the examination of the patient when indicated, performance or supervision of the procedure, interpretation and written report of the examination including procedure results (e.g., x-ray images), and consultation with the referring health care provider. To identify a charge for the professional component only, see Appendix A - Modifiers for modifier -26. Unless otherwise specified in the Schedule, the maximum allowable charge for the professional component is 60% of the listed Maximum Fee in the ATS@ column. 

The technical component includes the charges for personnel, materials and other supplies, and space, equipment, and other facilities, but excludes the cost of radioisotopes. To identify a charge for the technical component only, see Appendix A - Modifiers for modifier -TC. Unless otherwise specified in the Schedule, the maximum allowable charge for the technical component is 40% of the listed Maximum Fee in the ATS@ column. 

The total services component includes both the professional component and the technical component. The maximum fee is shown in the ATS@ column of this fee schedule. 

Hospital outpatient facilities and ambulatory surgical centers must specify, by use of modifiers, when only the technical component or the professional component is provided.