CMS Pub. 100-02, ch. 15, § 80.6.5

This exception applies to an independent laboratory’s pathologist or a hospital pathologist who furnishes a

pathology service to a beneficiary who is not a hospital inpatient or outpatient, and where the treating

physician/practitioner does not specifically request additional tests the pathologist may need to perform.

When a surgical or cytopathology specimen is sent to the pathology laboratory, it typically comes in a

labeled container with a requisition form that reveals the patient demographics, the name of the

physician/practitioner, and a clinical impression and/or brief history. There is no specific order from the

surgeon or the treating physician/practitioner for a certain type of pathology service. While the pathologist

will generally perform some type of examination or interpretation on the cells or tissue, there may be

additional tests, such as special stains, that the pathologist may need to perform, even though they have not

been specifically requested by the treating physician/practitioner. The pathologist may perform such

additional tests under the following circumstances:

• These services are medically necessary so that a complete and accurate diagnosis can be reported

to the treating physician/practitioner;

• The results of the tests are communicated to and are used by the treating physician/practitioner in

the treatment of the beneficiary; and

• The pathologist documents in his/her report why additional testing was done.

EXAMPLE:

A lung biopsy is sent by the surgeon to the pathology department, and the pathologist finds a granuloma

which is suspicious for tuberculosis. The pathologist cultures the granuloma, sends it to bacteriology, and

requests smears for acid fast bacilli (tuberculosis). The pathologist is expected to determine the need for

these studies so that the surgical pathology examination and interpretation can be completed and the

definitive diagnosis reported to the treating physician for use in treating the beneficiary.