Fix Common Diagnostic Lab Coding Errors

Palmetto GBA, Medicare administrative contractor (MAC) for jurisdiction 1 (J1), recently reported that the Comprehensive Error Rate Testing (CERT) contractor reported an increase in errors for complete blood counts (CBC) and urinalysis (UA) laboratory services.

According to the CERT report, data indicate two types of common errors:

  • Code selection errors
  • Standard protocol use in place of patient-specific physician orders

Sample Errors

In an Aug. 18 online article, Palmetto GBA gives the following two examples of common errors:

Example 1: A physician orders a CBC with automated differential WBC count (CPT® 85025 Blood count complete (CBC), automated (Hgb, Hct, RC, WBC and platelet count) and automated differential WBC count) or without automated differential WBC count (85027 Blood count complete (CBC), automated (Hgb, Hct, RC, WBC and platelet count)). Based on internal criteria, the lab examines a blood smear for additional verification. The lab may not report CPT® 85008 Blood count; blood smear microscopic examination without manual differential WBC count for the exam of a blood smear to complete the ordered automated hemogram test (CPT® 85025 or 85027) because National Correct Coding Initiative (NCCI) guidelines indicate it is a bundled service.

Example 2: A physician orders an automated hemogram (CPT® 85027) and a manual differential WBC count (CPT® 85007 Blood count; blood smear microscopic examination with manual differential WBC count). Both codes may be reported; however, an automated hemogram with automated differential WBC count (85025) may not be reported with a manual differential WBC count (CPT® 85007) because this results in duplicate payment for the differential WBC count.

Code Selection

Only lab services ordered by the physician should be provided and billed. A physician’s written order must match the performed service, Palmetto GBA advises.

  • Submit CPT® Codes 85014 Blood count; hematocrit (Hct) and 85018 Blood count; hemoglobin (Hgb) to report a hemoglobin and hematocrit level.
  • Submit CPT® Code 85027 to report a CBC to measure hemoglobin, hematocrit, red blood cell, white blood cell, and platelet levels.
  • Submit CPT® Code 85025 to report a CBC and differential white blood cell (WBC) count to measure the percentages of white blood cell types.

Remember: The medical record must document the medical indication for the ordered services, the specific order written by the physician and the test results of the ordered diagnostic tests.

Improper Protocols

Providers may not perform additional laboratory services based on internal standard or implied protocols, accord to the MAC. Medicare only covers patient-specific orders written by a physician. The following sample protocols are not covered Medicare services and may be subject to a recovery audit contractor (RAC) for corrective action.

  • Physician’s written order for a hemoglobin and hematocrit prompts the lab to perform a CBC
  • Physician’s written order for a CBC prompts the lab to perform a CBC with differential
  • White cells or bacteria discovered in a physician ordered urine test prompts the lab to perform a urine culture without a physicians order

Reference: Chapter 10, NCCI Policy Manual, Volume 15.3

Source: Palmetto GBA

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