Such services are actual medical services provided by physicians specifically trained in pathology.
The services involve the use of medical judgment.
Pathologists devote significant time and effort to these services and they contribute directly to the diagnosis, care, and treatment of individual patients.
Pathologists have professional responsibility and legal accountability for such services.
Certification standards including those promulgated under/by the Clinical Laboratory Improvement Amendments, the Joint Commission on Accreditation of Health care Organizations, and the College of American Pathologists require the performance of professional component services.
Such services are separate and distinct from the hospital’s technical component of clinical laboratory services which include equipment, facility, non-pathologist personnel, and other overhead costs.
The May 1999 edition of the CPT Assistant, which is produced by the American Medical Association, specifically references professional component billing for clinical laboratory services as appropriate, utilizing the 26 Modifier.
Federal case law (including federal case law within the Circuit applicable to Illinois), as well as Illinois state court case law; clearly support the propriety of professional component billing.
This case law has precedential value in Illinois as opposed to the recent Florida decision of Central States, Southeast and Southwest, Inc. vs. The Florida Society of Pathologists.
The Florida decision is not binding in Illinois and is only legally binding in a few counties in Florida.
The Florida decision does not stand for the proposition that professional component billing is improper, but only that pathologists must have an express contractual agreement with patients. This position is inconsistent with the above referenced federal and Illinois state court cases.
The Florida decision did not decide the issue of whether a payor is obligated under its contracts to pay for professional component services.