Practice Management Frequently Asked Questions

Based on established CAP policy, Practice Management makes no recommendation relative to specific charges. We recommend that you refer to the Medicare fee schedule and your third-party payers’ contract for the appropriate code and corresponding reimbursement.

Please refer to the handout or recording from a previous practice management roundtable, Ongoing Professional Practice Evaluation (OPPE) and Focused Professional Practice Evaluation (FPPE). 

The technical component represents the cost of performing the test (such as equipment and facility costs, supplies, non-physician work, and employee salaries). In pathology/histology terms that means embedding, sectioning, staining, tissue processing, slides, personnel working in histology, as well as report construction, dissemination and storage, and other administrative labor are considered part of the technical component. [Reference: Pathology Practice Management, ed. Hassell, Lewis, Talbert, Michael and Pine-Wood, Jane, 2016.]

The transcription function is part of the TC RVU values and is considered an indirect expense. Recommendation: Join the Practice Management Networking Community to stay informed about other pathology-focused topics.

Depending on the patient’s insurance and coverage, for non-emergency care to be considered a “surprise bill” for the purposes of the No Surprises Act protections, it must be a covered service and the care provided by an out-of-network provider as part of a visit to an in-network health care facility (so just being “unaware” is not necessarily enough). If a non-emergency service is not covered under the in-network benefits and terms of coverage under an individual’s health plan, then the No Surprises Act’s rules on balance billing do not apply to these services. We hope that the response above answers your question. If not, please feel free to reach out for further clarification.

Currently, Practice Management is not in a position to recommend consultants to individual groups. The CAP has sponsored many webinars, round table discussions, and talks about burnout, workload distribution, staffing challenges, etc. Many of these resources and the topic experts who provided them are referenced on the CAP website.

The transcription function is part of the TC RVU values and is considered an indirect expense. Recommendation: Join the Practice Management Networking Community to stay informed about other pathology-focused topics.

There is no standard for workload distribution or productivity evaluation for pathologists in the US. Pathologist productivity varies based upon several factors including, but not limited to, practice environment (hospital, academic, private), lab workflow, specimen mix (GI v derm v breast v hemepath v. clinical pathology v. medical directorship and other administrative duties, etc.), and case complexity. The CAP Practice Management Committee presented a webinar on this "Workload Distribution: Challenges and Opportunities for Pathology Groups” that can be viewed and downloaded.

Unfortunately, the CAP no longer has resources available for obtaining liability coverage. The responsibilities of a medical director are clearly defined in the Clinical Laboratory Improvement Amendments (CLIA) and are separate from the duties of a physician practicing laboratory medicine while rendering a diagnosis in a specific clinical situation. For further clarification, get formal legal advice, as needed.

Two expert opinions are cited below:Expert 1: "I typically recommend that the POS (place of service) reflect where the patient was collected. Thus POS 11 is for the physician's office, but POS 81 is acceptable since the billing entity is an independent lab, and of course, if the patient is a registered hospital patient, then POS 21, 22, or 19 must be used."Expert 2: "We've found inconsistencies in how payors want POS, even different Medicare carriers, other than of course correctly distinguishing facility vs non-facility vs non-facility, as otherwise payment rate is not affected."

The date of service (DOS) is a complex matter. It has long been the date of specimen collection, but in 2019 several Medicare administrators issued "billing guidance" stipulating that DOS is the date of collection when billing global service or TC only. Some commercial payers have adopted this guidance, but most pathology practices use the above rules when billing service for Medicare beneficiaries and use the date of specimen collection as the DOS when billing commercial payers.

The CMS describes the technical component (TC) as slide preparation only. We can find no references to CMS having ever reimbursed the cost of any post-diagnostic events such as the storage of slides, x-ray films, patient hospital charts, etc. As for laboratory cost accounting of filing the slides, it should be no different, in our opinion, from that related to filing charts, documents, or anything else and is included and accounted for in the job descriptions and overhead of the clerical staff.

Without knowing more details it is hard to provide succinct information. Some billing rules depend on the facility registration status of the patient – inpatient or outpatient. Any technical service should be billed to the facility where the patient is registered. This situation takes care of at least the technical component expense. Some rules depend on the payer; state Medicaid will not pay claims from out-of-state providers unless they are registered with the state program. Keeping in mind state licensing and direct billing limitations, one pathology group should not bill or pass along charges for professional services provided by another, unaffiliated pathology group. 

Negotiating with reference labs is a good option. Also discussing the issue with the medical executive or facility administration should be considered. Some pathology groups are successful at having the facility pay for the outside consultant services since the case most likely involved a facility patient (negotiated as part of the pathology service agreement). If it is the pathologist who wants a second opinion from an expert, then additional billing cannot occur. This explains why such experts have changed their policy of wanting payment up front and not billing patients or insurance. If the treating physician or patient requests a second opinion, the referring facility could bill them for it as long as it is clearly stated upfront in their policy. 

All in all, there are no obvious resources that discuss this issue.

The Practice Management Committee is not aware of such resources offered by the CAP. However, we are aware of members who did just what you suggest in their practice. We suggest that you post your question perhaps on LinkedIn or a MyCAP social community for a potential response and assistance.

The article, Applying the Staffing-to-Workload Methodology: Basic Staffing Model is a helpful resource addressing staffing of a clinical laboratory operation.

The official CAP policy regarding cases and volume distribution states that these numbers need to be determined locally based on each practice setting.

We encourage you to join our Practice Management Networking Community at as it will keep you regularly informed about all things practice management and group leadership. There is no fee to join the community. You only need to be sponsored by a CAP Fellow.

It is our understanding that any group or entity handling privileged patient medical information (PMI), under any form (medical reporting, billing, etc.), needs to have a HIPAA compliance policy in place, clearly delineating the protection and handling of such information.

The official CAP policy regarding cases and volume distribution states that these numbers need to be determined locally based on each practice setting.