[Code of Federal Regulations]

[Title 42, Volume 2]

[Revised as of October 1, 2005]

From the U.S. Government Printing Office via GPO Access

[CITE: 42CFR415.130]



[Page 797-798]

 

                         TITLE 42--PUBLIC HEALTH

 

                    CHAPTER IV--CENTERS FOR MEDICARE

                          & MEDICAID SERVICES,

                        DEPARTMENT OF HEALTH AND

                             HUMAN SERVICES

 

PART 415_SERVICES FURNISHED BY PHYSICIANS IN PROVIDERS, SUPERVISING 

PHYSICIANS IN TEACHING SETTINGS, AND RESIDENTS IN CERTAIN SETTINGS

--Table of Contents

 

      Subpart C_Part B Carrier Payments for Physician Services to 

                       Beneficiaries in Providers

 

Sec. 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 

Sec. 415.102(a) and are one of the following services:



[[Page 798]]



    (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. The technical component of physician pathology services 

furnished by an independent laboratory to a hospital inpatient or 

outpatient before January 1, 2001 may be paid to the laboratory on a fee 

schedule basis. After December 31, 2000 but before January 1, 2003, if 

an independent laboratory furnishes the technical component of a 

physician pathology service to a fee-for-service Medicare beneficiary 

who is an inpatient or outpatient of a covered hospital, the carrier 

will treat the technical component as a service for which payment will 

be made to the laboratory under the physician fee schedule. For these 

two years the service will not be treated as an inpatient hospital 

service for which payment is made to the hospital under section 1886(d) 

of the Act or as an outpatient hospital service for which payment is 

made to the hospital under section 1833(t) of the Act. After December 

31, 2002, the technical component for physician pathology services 

furnished by an independent laboratory to a hospital inpatient or 

outpatient is paid only to the hospital.



[60 FR 63178, Dec. 8, 1995, as amended at 64 FR 59442, Nov. 2, 1999; 66 

FR 55332, Nov. 1, 2001]