---
kind: "section"
citation: "42 C.F.R. § 415.130"
title: "42"
number: "415.130"
heading: "Conditions for payment: Physician pathology services."
url: "https://uscodex.org/cfr/42/415.130"
---

# §415.130. Conditions for payment: Physician pathology services.

- (a) **Definitions.** The following definitions are used in this section.
  - (1) **Covered hospital—** means, with respect to an inpatient or an outpatient, a hospital that had an arrangement with an independent laboratory that was in effect as of July 22, 1999, under which a laboratory furnished the technical component of physician pathology services to fee-for-service Medicare beneficiaries who were hospital inpatients or outpatients, and submitted claims for payment for this technical component directly to a Medicare carrier.
  - (2) Fee-for-service Medicare beneficiaries means those beneficiaries who are entitled to benefits under Part A or are enrolled under Part B of Title XVIII of the Act or both and are not enrolled in any of the following:
    - (i) **A Medicare + Choice plan under Part C of Title XVIII of the Act.**
    - (ii) A plan offered by an eligible organization under section 1876 of the Act;
    - (iii) A program of all-inclusive care for the elderly (PACE) under 1894 of the Act; or
    - (iv) A social health maintenance organization (SHMO) demonstration project established under section 4018(b) of the Omnibus Budget Reconciliation Act of 1987.
- (b) **Physician pathology services.** The carrier pays for pathology services furnished by a physician to an individual beneficiary on a fee schedule basis only if the services meet the conditions for payment in [§ 415.102(a)](/cfr/42/415.102.md?p=a) and are one of the following services:
  - (1) **Surgical pathology services.**
  - (2) Specific cytopathology, hematology, and blood banking services that have been identified to require performance by a physician and are listed in program operating instructions.
  - (3) **Clinical consultation services that meet the requirements in paragraph (c) of this section.**
  - (4) Clinical laboratory interpretative services that meet the requirements of paragraphs [(c)(1)](#c-1), [(c)(3)](#c-3), and [(c)(4)](#c-4) of this section and that are specifically listed in program operating instructions.
- (c) **Clinical consultation services.** For purposes of this section, clinical consultation services must meet the following requirements:
  - (1) **Be requested by the beneficiary's attending physician.**
  - (2) Relate to a test result that lies outside the clinically significant normal or expected range in view of the condition of the beneficiary.
  - (3) **Result in a written narrative report included in the beneficiary's medical record.**
  - (4) **Require the exercise of medical judgment by the consultant physician.**
- (d) **Physician pathology services furnished by an independent laboratory.**
  - (1) The technical component of physician pathology services furnished by an independent laboratory to a hospital inpatient or outpatient on or before June 30, 2012, may be paid to the laboratory by the contractor under the physician fee schedule if the Medicare beneficiary is a patient of a covered hospital as defined in [paragraph (a)(1)](#a-1) of this section.
  - (2) For services furnished after June 30, 2012, an independent laboratory may not bill the Medicare contractor for the technical component of physician pathology services furnished to a hospital inpatient or outpatient.
  - (3) For services furnished on or after January 1, 2008, the date of service policy in [§ 414.510](/cfr/42/414.510.md) of this chapter applies to the TC of specimens for physician pathology services.

## Notes

### Amendments

[60 FR 63178, Dec. 8, 1995, as amended at 64 FR 59442, Nov. 2, 1999; 66 FR 55332, Nov. 1, 2001; 71 FR 69788, Dec. 1, 2006; 72 FR 66405, Nov. 27, 2007; 73 FR 69938, Nov. 19, 2008; 75 FR 73626, Nov. 29, 2010; 76 FR 73473, Nov. 28, 2011; 77 FR 69371, Nov. 16, 2012]

### Authority

Authority: 42 U.S.C. 1302 and 1395hh.

### Source

Source: 60 FR 63178, Dec. 8, 1995, unless otherwise noted.

### Amendments

[60 FR 63178, Dec. 8, 1995, as amended at 64 FR 59442, Nov. 2, 1999; 66 FR 55332, Nov. 1, 2001; 71 FR 69788, Dec. 1, 2006; 72 FR 66405, Nov. 27, 2007; 73 FR 69938, Nov. 19, 2008; 75 FR 73626, Nov. 29, 2010; 76 FR 73473, Nov. 28, 2011; 77 FR 69371, Nov. 16, 2012]