Page 119 - Medicare Benefit Policy Manual

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 no
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 the pathologist 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; and

• The pathologist documents in his/her report why additional testing was done.

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.

90 - X-Ray, Radium, and Radioactive Isotope Therapy
(Rev. 1, 10-01-03)
B3-2075

These services also include materials and services of technicians.

X-ray, radium, and radioactive isotope therapy furnished in a nonprovider facility require
direct personal supervision of a physician. The physician need not be in the same room,
but must be in the area and immediately available to provide assistance and direction
throughout the time the procedure is being performed. This level of physician
involvement does not represent a physician’s service and cannot be billed as a Part B
service. The physician would have to furnish a reasonable and necessary professional
service as defined in §§30 of this chapter, in order for the physician’s activity to be
covered.

However, effective for radiation therapy services furnished on or after April 1, 1989,
radiologists’ weekly treatment management services are covered.