§ 415.130 Conditions for payment: Physician pathology services. ( a ) *Definitions.* The following definitions are used in this section. ( 1 ) *Covered hospital* means, with respect to an inpatient or an outpatient, a hospital that had an arrangement with an independent laboratory that was in effect as of July 22, 1999, under which a laboratory furnished the technical component of physician pathology services to fee-for-service Medicare beneficiaries who were hospital inpatients or outpatients, and submitted claims for payment for this technical component directly to a Medicare carrier.
( 2 ) *Fee-for-service Medicare beneficiaries* means those beneficiaries who are entitled to benefits under Part A or are enrolled under Part B of Title XVIII of the Act or both and are not enrolled in any of the following: ( i ) A Medicare + Choice plan under Part C of Title XVIII of the Act.
( ii ) A plan offered by an eligible organization under section 1876 of the Act;
( iii ) A program of all-inclusive care for the elderly (PACE) under 1894 of the Act; or
( iv ) A social health maintenance organization (SHMO) demonstration project established under section 4018(b) of the Omnibus Budget Reconciliation Act of 1987.
( b ) *Physician pathology services.* The carrier pays for pathology services furnished by a physician to an individual beneficiary on a fee schedule basis only if the services meet the conditions for payment in § 415.102(a) and are one of the following services: ( 1 ) Surgical pathology services.
( 2 ) Specific cytopathology, hematology, and blood banking services that have been identified to require performance by a physician and are listed in program operating instructions.
( 3 ) Clinical consultation services that meet the requirements in paragraph (c) of this section.
( 4 ) Clinical laboratory interpretative services that meet the requirements of paragraphs (c)(1), (c)(3), and (c)(4) of this section and that are specifically listed in program operating instructions.
( c ) *Clinical consultation services.* For purposes of this section, clinical consultation services must meet the following requirements: ( 1 ) Be requested by the beneficiary's attending physician.
( 2 ) Relate to a test result that lies outside the clinically significant normal or expected range in view of the condition of the beneficiary.
( 3 ) Result in a written narrative report included in the beneficiary's medical record.
( 4 ) Require the exercise of medical judgment by the consultant physician.
( d ) *Physician pathology services furnished by an independent laboratory.* ( 1 ) The technical component of physician pathology services furnished by an independent laboratory to a hospital inpatient or outpatient on or before June 30, 2012, may be paid to the laboratory by the contractor under the physician fee schedule if the Medicare beneficiary is a patient of a covered hospital as defined in paragraph (a)(1) of this section.
( 2 ) For services furnished after June 30, 2012, an independent laboratory may not bill the Medicare contractor for the technical component of physician pathology services furnished to a hospital inpatient or outpatient.
( 3 ) For services furnished on or after January 1, 2008, the date of service policy in § 414.510 of this chapter applies to the TC of specimens for physician pathology services.
[60 FR 63178, Dec. 8, 1995, as amended at 64 FR 59442, Nov. 2, 1999; 66 FR 55332, Nov. 1, 2001; 71 FR 69788, Dec. 1, 2006; 72 FR 66405, Nov. 27, 2007; 73 FR 69938, Nov. 19, 2008; 75 FR 73626, Nov. 29, 2010; 76 FR 73473, Nov. 28, 2011; 77 FR 69371, Nov. 16, 2012]