Pathology/Lab Coding Alert

CMS was quick to add Correct Coding Initiative (CCI) edit pairs for the new CPT 2003 codes in CCI version 9.0, providing clear coding restrictions for many services.

Many new edit pairs involve CPT Codes 2003 additions, such as codes for hematology, Pap smears, apheresis procedures and stem cell harvesting. "Although many of the new edit pairs represent services that would not likely be performed concurrently, coders must be aware of the changes in order to override the edit on the occasion that these services legitimately occur together," says William Dettwyler, MT-AMT, coding analyst for Health Systems Concepts, a laboratory coding and compliance consulting firm in Longwood, Fla. CCI Edits version 9.0 is effective Jan. 1 through March 31. CCI Identifies Inappropriate Coding " CCI Edits pairs represent services that are bundled (components of a more comprehensive service) or would not ordinarily be performed together for the same patient on the same day (mutually exclusive services)," says Laurie Castillo, MA, CPC, CPC-H, CCS-P, member of the National Advisory Board of the American Academy of Professional Coders and president of Physician Coding and Compliance Consulting in Virginia. Medicare will not reimburse both services when they are reported together.

If the two services of a code pair are carried out as distinct and independent services that are medically necessary, however, Medicare may reimburse with the appropriate modifier. To indicate that codes represent separate services as opposed to unbundling of a single service, append modifier -59 (Distinct procedural service) to override the edit. For clinical lab tests conducted more than once a day, use modifier -91 (Repeat clinical diagnostic laboratory test). Every code pair is assigned a "modifier indicator" of either "1," which means a modifier can be used with the pair, or "0," which means a modifier cannot be used. You should ensure that your lab does not indiscriminately override CCI edit pairs, and that when you do, you have appropriate documentation in the medical record to justify the claim of distinct procedural service. New Hematology Section All Bundled Up CPT 2003 overhauled the hematology codes, and CCI 9.0 quickly bundled them up. The two comprehensive blood count codes in CPT 2003 are 85025 (Blood count; complete [CBC], automated [Hgb, Hct, RBC, WBC and platelet count] and automated differential WBC count) and 85027 (Blood count; complete [CBC], automated [Hgb, Hct, RBC, WBC and platelet count]). "CCI 9.0 disallows reporting these two codes together and also bundles them with each of the components," Dettwyler explains. The components are as follows:   85004 Blood count; automated differential WBC count.     85009 ... manual differential WBC count, buffy coat. This is bundled with 85025, not 85027.   [...]