Pathology/Lab Coding Alert

Avoid unlisted-procedure codes for new tests Don't ignore those strange alphanumeric codes listed at the back of your CPT book. You should be using those Category III codes because they will pay off in the future.
 
The problem: Your natural instinct is to leave these codes alone because Medicare won't pay for many Category IIIs but will pay for unlisted-procedure codes. But if you choose to stick only with the tried-and-true Category I codes, you're cheating yourself out of future payment.
 
What they are: The AMA developed CPT III codes for new and emerging technologies, says Franz Ritucci, MD, DABAM, FAEP, director of the American Academy of Ambulatory Care in Orlando, Fla. And because the AMA uses the codes to gather usage data, reporting Category IIIs could contribute to creating future Category I codes that will pay.
 
Unlike lab tests for Category I codes, Category III lab tests may not have Food and Drug Administration approval. And the AMA disclaims that including a test as a Category III code implies "clinical efficacy or safety." But if your lab uses the test, you should use the code.
 
Important: In fact, AMA coding instruction requires that "if a Category III code is available, this code must be reported instead of a Category I unlisted code."
 
Example: A lab performs a phospholipid cofactor antibody test. The coder should bill Category III code 0030T (Antiprothrombin [phospholipid cofactor] antibody, each Ig class) to Medicare. For private payers, however, you may need to bill 86849 (Unlisted immunology procedure). Contact your payers for billing and payment instructions.

Learn How to Find Category III Codes If your lab is doing a new test and you don't know the CPT code, how can you find out if a Category III code describes the test?
 
Predicament: Unlike Category I codes, Category III codes aren't subdivided by type of service. They're listed in increasing numerical order based on the year the code was added. You might have a surgical code and a lab test next to each other, so how can you find the codes you need?
 
Solution: Use our handy tool, "Put Category III Lab Codes at Your Fingertips," on page 53. We've done the work for you and listed all Category III codes that labs might use, along with a description of common clinical applications and methods to help you identify the test.
 
You'll also find lots of references in CPT text notes that will help you know when a similar test has a Category III code assigned.
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