Further IFE testing on bone marrow.

Q A pathologist is requested to perform a bone marrow on an outpatient. On interpreting the bone marrow, the pathologist would like to perform an immunoelectrophoresis, or IFE. No order was received for an IFE when the patient was presented. The pathologist would like to draw a serum sample to have available should the patient's bone-marrow results indicate the need for an IFE in order to make a more definitive diagnosis. Medicare Benefit Policy Transmittal 80 indicates only the treating physician is to request the diagnostic test. Can the pathologist have a serum specimen drawn in case he believes an IFE is needed based on the wording of this transmittal?

A As with a recently answered "Tips" question, added-on tests not ordered by the attending physician cause a billing problem with Medicare and some insurance companies. (1) This question, however, is more open to interpretation by different Medicare fiscal intermediaries and insurance companies.

Centers for Medicare and Mediaid Services (CMS) Transmittal [80.sup.2] indicates that it is acceptable for a pathologist to add additional tests on a surgical or cytology specimen if they are necessary for interpretation of the specimen: "80.6.5-Surgical/Cytopathology Exception (Rev. 80; Issued: 11-11-08; Effective: 01-01-03; Implementation: 11-19-07). This exception applies to an independent laboratory's pathologist or a hospital pathologist who furnishes a pathology service to a beneficiary who is not a hospital inpatient or outpatient, and where the treating physician/practitioner does not specifically request additional tests the pathologist may need to perform. When a surgical or cytopathology specimen is sent to the pathology laboratory, it typically comes in a labeled container with a requisition form that reveals the patient demographics, the name of the physician/practitioner, and a clinical impression and/or brief history. There is not specific order from the surgeon or the treating physician/practitioner for a certain type of pathology service.

While the pathologist will generally perform some type of examination or interpretation on the cells or tissue, there may be additional tests such as special stains that he may need to perform, even though they have not been specifically requested by the treating physician/practitioner. The pathologist may perform such additional tests under the following circumstances:

* These services are medically necessary so that a complete and accurate diagnosis can be reported to the treating physician/practitioner.

* The results of the tests are communicated to and are used by the treating physician/practitioner in the treatment of the beneficiary.

* The pathologist documents in his report why additional testing was done.

For example, a lung biopsy is sent by the surgeon to the pathology department, and the pathologist finds a granuloma, which is suspicious for tuberculosis. The pathologist cultures the granuloma, sends it to bacteriology, and requests smears for acid-fast bacilli (tuberculosis). The pathologist is expected to determine the need for these studies so that the surgical-pathology examination and interpretation can be completed and the definitive diagnosis reported to the treating physician for use in treating the beneficiary." (2)

This rule applies only to the specimen and would appear not to allow ordering of an Immunoelectrophoresis on an additional blood specimen. There is, however, a situation where this might be allowed. It depends on the pathologist's relationship with the patient and patient's physician.

If the pathologist has been called in as a consultant who not only will make a diagnosis but also advise the physician on the management of the patient, he becomes a "treating physician" rather than an "interpreting physician." A "treating physician" is a physician defined in [section] 1861 (r) of the Social Security Act as "one who furnishes a consultation or treats a beneficiary for a specific medical problem, and who uses the results of a diagnostic test in the management of the beneficiary's specific medical problem."

In another "example, a radiologist performing a therapeutic interventional procedure is considered a treating physician. A radiologist performing a diagnostic interventional or diagnostic procedure is not considered a treating physician." (2) The Transmittal clearly states the conditions under which an interpreting physician may order additional tests, not included in the original order. (2)

In summary, unless the pathologist is the patient's treating physician, he cannot order additional tests that require an additional specimen. Additional tests on the existing specimen such as special stains to clarify the diagnosis for which the specimen was submitted would only be allowed if conditions listed in Transmittal 80 were met.

--Daniel M. Baer, MD

References

(1.) Pontius, A. Billing for confirmatory tests. Med Lab Observ. 2008;40(3):51.

(2.) CMS manual system. Pub 100-02 Medicare benefit policy, Transmittal 80. Centers for Medicare and Medicaid Services (CMS). http://www.cms.hhs. gov/Transmittals/Downloads/R80BP.pdf. Published January 11,2008. Accessed April 13,2008.