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California Society of Pathologists
One Capitol Mall Suite 320
Sacramento, CA 95814 
Tel : 916-446-6001
Fax :  916-444-7462

CSP Successful in Reversing Medi-Cal Decision to Deny Professional Component Billing for Clinical Pathology

We are pleased to report that after a series of discussions with the Rate Development and Medical Policy branches of the Department of Health Care Services ( DHCS) they have informed us that they are rescinding the policy announcement that would have denied -26 or professional component billing for most clinical pathology codes in the hospital setting. The policy change did take effect for dates of service on or after 2/1/10, but they will be reversing that policy and edits. It will not happen immediately and we will know more in a few days as to the timing for the change.


They will let inform the CSP on how long it will take EDS/HP to make the systems changes to restore -26 payments for these codes. It could take 2 days, 2 weeks, or a month. Any claims that do get denied would be reprocessed and paid via an Electronic Payment Correction (EPC) so whether you hold your claims or not they will eventually be paid correctly.


The DHCS policy was promulgated to make Medi-Cal conform to current Medicare policy which does not recognize a PC component under Part B for most clinical pathology services, but instead classifies the pathologist effort and responsibility as a Part A service payable through the hospital. We informed DHCS that the Medicare payment system is different then Medi-Cal and that Medi-Cal in its contracts with hospitals either includes or excludes the PC of clinical pathology in their per diem payment to the hospital. When it is excluded the pathologist is able to bill that PC for Medi-Cal patients and it is the only source of compensation for their services. They indicated that they had not considered that fact when revising the policy and will make that change. The prohibition on separate billing for these services on a -26 basis outside the hospital will continue.


We are pleased with the ability to have this discussion and the willingness of DHCS to make this prudent change. We will provide more information as it becomes available.