Highmark Medicare Services is the Medicare Part B contractor for Pennsylvania and the Medicare Part A contractor for Pennsylvania, Maryland, and the District of Columbia.  As such, Highmark Medicare Services processes claims for Part A and Part B Medicare services provided in these locales.  RedPath Integrated Pathology, Inc., is a CLIA, CAP accredited reference laboratory located in Pittsburgh, Pennsylvania.  RedPath provides advanced molecular topographic genotyping utilizing its PathFinder TG^® process when microscopic analysis and special staining methods cannot provide the needed definitive diagnosis on specimens sent to RedPath by Pathologists and Facilities from across the U.S.

As there does not exist a specific CPT/HCPCS code or codes to define the PathFinder TG^® service, claims for this service have been billed to Medicare using a variety of coding combinations and not otherwise classified (NOC) codes.  This article will address coding instructions and Highmark Medicare Services’ Individual Consideration of these services when provided to Medicare beneficiaries and billed to Medicare.

Until more specific coding instructions are issued, or specific CPT/HCPCS codes are developed, claims for these services will be billed and processed utilizing the not otherwise classified code 84999 with the description “PathFinder TG” noted on the claim descriptor for this NOC code.  In addition, the -26 or -TC modifiers will be utilized with the 84999 code when billing for only the professional (-26) or technical (-TC) components of these services, when appropriate.

The Physician referring the case(s) to RedPath must prepare and sign a request/requisition for RedPath’s PathFinder TG^® diagnostic assay and must clearly indicate the following on the request:

1. Date sample/specimen obtained; Date sample/specimen sent to RedPath;
   
   
2. Place of service where sample/specimen obtained (inpatient hospital, outpatient hospital, Ambulatory Surgical Center, etc.);
   
   
3. Clinical history and rationale for referring the case for further analysis.

Highmark Medicare Services will review and process those RedPath PathFinder TG^® services in keeping with all CMS Medicare instructions and the clinically appropriate utilization.  In keeping with

§ 1395y(a)(1)(A), §1320c-5(a)(1-3), §1320a-7(b)(6)(8) and §1395n(a)(2)(8) of 42 U.S.C., providers billing Medicare for services will provide clinical documentation to Medicare upon request that the service(s) rendered and billed were “reasonable and necessary”, economical and not substantially in excess of the needs of such patients.  To this extent, it is expected that the clinical documentation will include (but not be limited to):

• Specific reasons for the additional testing to include how results will change patient management;
  
• Verification of patient notification that additional testing via RedPath’s PathFinder TG^® process and assays has been requested; and
  
• Evidence that the service was provided in keeping with published peer-reviewed literature and utilization criteria which includes:
  
  • PathFinder TG^® is not intended for “first-line” pathology analysis;
    
  • PathFinder TG^® is to be utilized only when an indeterminate diagnosis of malignancy remains after traditional pathologic and microscopic staining and analysis; and
    
  • PathFinder TG^® should only be utilized when its use will result in targeted, patient specific treatment and effective utilization of healthcare resources.