"Under the Looking Glass" A Closer Look at Coding Lab/Path

Presented by

Rita Genovese, CPC

Agenda

• Lab/Path Testing Categories

• Coding Tips

• 2013 Code Changes – At a Glance

• Diagnostic Coding

• Lab Fee Schedule

• National Correct Coding Initiative – Modifiers

• Discussion

Laboratory/Pathology Testing

• Categories of Testing

1. Screening

• No established diagnosis

• No signs or symptoms

2. Diagnosing

• There are signs and symptoms

3. Monitoring

• There is a diagnosis

• There is a treatment, care plan or medication

Path/Lab Coding Tips

• CPT codes - 80000 series

• Important terminology needed for code selection:

– Specimen, Method, Total or Free

– Manual or automated

– Qualitative or Quantitative

– Initial

– Antibody vs. Antigen codes series

Path/Lab Coding Tips

• When more than one code is needed: – Charge explosions

• refers to a series or bundles of codes that can be invoked through a single line item charge.

• In lieu of entering all of the individual codes , one code may be used that then “explodes” into the list of codes – Commonly used for Panels , Profiles and Reflex Tests

• When there isn’t a code – Be careful when using unlisted procedure codes

– Use testing method codes

2013 Code Changes

• LOTS!!! • Guideline changes

– Evocative/Suppression testing – Molecular Pathology – Chemistry

• Definitions clarifications/updates • Changes

– Cytopathology – Microbiology – Transfusion Medicine – Tier 1: 13 new codes – Tier 2: represents medically useful procedures performed in

lower volumes than Tier 1

2013 Code Changes

• Code additions

– Chemistry

– Immunology

– Tissue typing

– Microbiology

– Cytopathology

– Surgical Pathology

– Molecular Pathology

2013 Code Changes - Chemistry

• 82009-82010 were updated to reflect current techniques with example tests

• 82777 added to report Galectin-3

2013 Code Changes - Immunology

• 86152-86153 were created to report circulating tumor cell testing (CTC), interpretation and reporting

(Replace Category III codes previously

reported by 0278T and 0280T)

• 86711 added to report JC virus testing

Tissue Typing

• 86828-86835 were created to report HLA

testing

2013 Code Changes - Microbiology

• 87910 added to report nucleic acid probe technique for detection of cytomegalovirus

• 87912 added to report nucleic acid detection of Hepatitis B virus

• 87631-87633, 87910, 87912 – Infectious agent detection by nucleic acid

Cytopathology

• 88184-88189

– Should only be used to report the detection of markers as used in the assessment of hematologic conditions

Surgical Pathology

• 88375

– For interpretation and reporting of optical endomicroscopic images

Molecular Pathology

• 60452-26 used by pathologists when an interpretation of a molecular pathology test is performed

– replacing: 83912-26

Molecular Pathology

• 81161

• 81201, 81203

• 81235

• 81252-81254

• 81321- 81326

• 81400-81408

• Unlisted Molecular Biology Procedure: 81479

Multianalyte Assays (MAAA)

• 81500 – ROMA

• 81503 – OVA 1

• 81599 – Maternal Serum Screening

Deleted Codes

• 83890-83914

– Molecular pathology codes

• 88384-88386

– Assay-based evaluation codes

Revised Codes

• 81400 Molecular Path Procedure Level 1

• 81401 FGFR3

• 81402 Molecular Path Procedure Level 3

• 81403 Molecular Path Procedure Level 4

• 82009 Ketone Body Qualitative

• 86891 Intra- or post-operative salvage

Revised Codes

• 87498 Enterovirus amplified probe technique

• 87521 Hep C amplified probe technique

• 87522 Hep C quantifications

• 87535-87536 HIV 1

• 87538-87539 HIV 2

Diagnostic Services

• ICD-9 coding

– Sequencing:

• Diagnosis

• Condition

• Problem

• Other (reason for encounter/ visit)

• Other diagnoses may be sequenced as additional diagnoses

Diagnostic Services

ICD-9 coding:

– When patients receive only diagnostic services during an encounter, the appropriate V code for the examination is sequenced first

– The diagnosis/problem for which the services are being performed is sequenced second

Diagnostic Services

ICD-9 coding

• For routine lab testing, with no signs, symptoms, or associated diagnosis, use: – V72.60, V72.61, V72.62

– Be sure to pay attention to the “includes” and “excludes” in the appropriate V codes, as this may impact the final diagnosis used for billing purposes

Diagnostic Services

• V72.6x

– used to describe the reason for the encounter (e.g. study biopsy specimen)

• If there’s an established diagnosis, an additional code should be submitted for the diagnosis

Diagnostic Services

• If routine testing is performed at the same encounter as a test to evaluate a sign, symptom, or diagnosis, it is appropriate to assign both the V code and the code describing the reason for the non-routine test.

Diagnostic Services – Pro Fee

• For outpatient encounters for diagnostic tests that have been interpreted by a physician, and the final report is available at the time of coding – code any confirmed or definitive diagnosis(es)

documented in the interpretation

• Do not code related signs and symptoms as additional diagnoses

CMS Clinical Lab Fee Schedule

CMS Clinical Lab Fee Schedule

2013 Clinical Diagnostic Laboratory Fee Schedule

WI IL MN CA1 HI

National Mid 951 952 954 1102 1202

HCPCS Modifier Limit Point Loc 00 Loc 00 Loc 00 Loc 00 Loc 00

36415 $0.00 $3.00 $3.00 $3.00 $3.00 $3.00 $3.00

78267 $10.81 $14.61 $10.81 $10.81 $10.81 $10.81 $10.81

78268 $92.59 $125.12 $92.59 $92.59 $92.59 $92.59 $92.59

80047 $11.63 $15.71 $11.63 $11.63 $11.63 $11.63 $11.63

80047 QW $11.63 $15.71 $11.63 $11.63 $11.63 $11.63 $11.63

80048 $11.63 $15.71 $11.63 $11.63 $11.63 $11.63 $11.63

80048 QW $11.63 $15.71 $11.63 $11.63 $11.63 $11.63 $11.63

80051 $9.64 $13.03 $9.64 $9.64 $9.64 $9.64 $9.64

80051 QW $9.64 $13.03 $9.64 $9.64 $9.64 $9.64 $9.64

80053 $14.53 $19.63 $14.53 $14.53 $14.53 $14.53 $14.53

80053 QW $14.53 $19.63 $14.53 $14.53 $14.53 $14.53 $14.53

National Correct Coding Initiative (NCCI) – Modifier 59

• Modifier -59 is used (to identify):

– procedures/services that are not normally reported together, but are appropriate under certain circumstances

– designate instances when distinct and separate multiple services are provided to a patient on a single date of service

– separate sessions or patient encounters, or different procedures

– if the same procedure using the same procedure code is used for testing a different specimen (e.g. aerobic culture of two independent wound site specimens)

NCCI - Modifier 59

• Modifier -59 is NOT used when a test is ordered and performed and additional related procedures are necessary to provide or confirm the result

– These additional tests are considered part of the ordered test

• Example – A patient has an abnormal test result and the Pathologist repeat s the test to verify the result

Modifier -90 Reference Laboratory

• When laboratory procedures are performed by a party other than the treating or reporting physician, the procedure may be identified by adding modifier -90 to the usual procedure number

NCCI - Modifier 91

Repeat Clinical Diagnostic Test

• Modifier -91 is used to identify repeat performance of the same laboratory test on the same day to obtain subsequent (multiple) test results

– Example: If a second culture was performed from the same site on the same day

NCCI - Modifier 91

• Modifier -91 is NOT used when tests are re-run to confirm initial results due to testing problems when a normal, one-time reportable result is all that is required

Discussion