American Cancer Society
American Medical Association
College of American Pathologists (CAP)
Centers for Disease Control and Prevention
Centers for Medicare and Medicaid Services
Florida Agency for Health Care Administration
American Society for Clinical Pathology
Frequently Asked Questions
What is a pathologist?
A pathologist is a physician trained and experienced to study the nature, cause, and development of diseases, and the structural and functional changes caused by them. The diagnosis is established after studying body tissue, fluids, secretions, and/or other types of specimens and evaluating the presence and stage of disease, while utilizing laboratory procedures and special equipment. Many refer to the pathologist as “the doctor’s doctor,” because in addition to determining the diagnosis, the pathologist acts as consultant to other medical practitioners. The pathologist may also perform autopsies to determine nature and extent of disease, cause of death, and effects of treatment. Due to the complex nature of pathology, modern pathologists require expert training to specialize in fields such as bone and soft tissue, breast, OB/GYN, and pediatric pathology.
What are the fields of pathology?
The field of pathology has two distinct branches: Anatomic Pathology and Clinical Pathology. As a patient, it is important to understand the distinction between these branches. The easiest way to understand this concept is to think of anatomic pathology as the branch of pathology dealing with examining diagnostic tissue, while clinical pathology deals primarily with bodily fluids.
Why did I get a bill from RHA?
RHA pathologists operate within many hospitals in Florida and the U.S. Virgin Islands. They also work with academic institutions, such as the University of South Florida, and affiliated physician offices, as well as surgery centers. A bill will be issued to a patient or the appropriate responsible party when pathology services are rendered for the professional component of anatomic or clinical pathology. For patients with health insurance, a bill is issued only after the health insurance plan has been billed and a claim processed.
I received a bill from RHA, but I did not see a pathologist?
Pathologists rarely meet with patients face to face as they perform services in a laboratory setting. Your physician or other medical practitioner refers specimens directly to the laboratory for examination and/or processing, thus it is normal to have not seen the pathologist who performed the services for which you have been billed.
My insurance company denied RHA’s claim for Clinical Pathology as not covered; they state that the use of the modifier 26 is incorrect. Why am I responsible for the bill if insurance disallows it?
Clinical Pathology denials result when private insurance companies follow Medicare payment policies in error. The assertion of Medicare payment rules, to non-Medicare accounts, wrongly asserts that Medicare does not cover professional component services. In fact, Medicare provides for payment for the professional component of clinical pathology services under Medicare Part A. For non-Medicare patients, professional component billing is one of the most common methods of compensating pathologists for their services in a clinical laboratory and is supported by The College of American Pathologists (CAP). Further, the American Medical Association (AMA) supports the use of modifier 26 when the professional component of the procedure is being reported separately.
What services constitute the professional component of Clinical Pathology?
Pathologists, serving as medical directors of laboratories, provide valuable and necessary medical services for all patients for which they assume medical responsibility and legal liability. The services and responsibilities are many and varied and focus, in large part, on ensuring that the results of laboratory tests are timely, medically reliable, and clinically useful. In fact, many of these duties and responsibilities are mandated by the federal law. These essential medical services include:
- Assuring that tests, examinations, and procedures are properly performed, recorded, and reported;
- Interacting with members of the medical staff regarding issues of laboratory operations, quality, and test availability;
- Designing protocols and establishing parameters for performance of clinical testing;
- Recommending appropriate follow-up diagnostic tests, when appropriate;
- Supervising laboratory technicians and advising technicians regarding aberrant results;
- Selecting, evaluating, and validating test methodologies;
- Directing, performing, and evaluating quality assurance and control procedures;
- Evaluating clinical laboratory data and establishing a process for review of test results prior to issuance of patient reports;
- Assuring the laboratory’s compliance with State licensure laws, Medicare Conditions of Participation, Joint Commission on Accreditation of Healthcare Organizations standards, the College of American Pathologists Laboratory Accreditation Program, and Federal certification standards.