Pathology/Lab Coding Alert

Make sure you update your 'covered' ICD-9 codes

With new ICD-9-CM codes effective Oct. 1, your lab's "covered diagnosis" list can be a moving target. To get paid for tests covered under Medicare's National Coverage Determination (NCD) rules, you'll have to update your diagnosis code sets and make sure your physician clients do too.

Physician Assigns Ordering Diagnosis Your lab stands to lose if you perform a test without an ICD-9 code on Medicare's covered diagnosis list. "But you have to use the ICD-9 code or narrative diagnosis supplied by the ordering physician - which can leave your lab in a bind if it's not covered," says Laurie Castillo, MA, CPC, CPC-H, CCS-P, owner of Castillo Consulting in Manassas, Va.

Use the summary chart to see NCD "covered diagnosis" code changes based on ICD-9 2005.

Tip: Make sure you have documentation that supports payable diagnoses for ordered lab tests. "Your lab can update requisition forms to reflect current diagnosis codes and ensure accurate physician ordering," Castillo says. If you don't have a payable diagnosis, you'll need to get a signed Advance Beneficiary Notification (ABN) and report the lab code with modifier -GA (Waiver of liability statement on file) so you can bill the patient for the test. You Won't Get Paid for Truncated Codes Whether you assign the ICD-9 code based on the physician's narrative diagnosis, or the physician assigns the ordering ICD-9, you must report the code to the highest degree of specificity. "That means no 'truncated codes' - using a general, three- or four-digit code instead of a more specific four- or five-digit code when one is available," Castillo says.

CMS made many of the NCD covered diagnoses changes shown in the chart to avoid truncated codes. Because ICD-9 2005 provides more specific codes for some conditions, you'll have to use the new five-digit code rather than the invalid four-digit code it replaces.

Watch out: Even if the medical record does not clearly define a condition, you should not use an incomplete, truncated code. Instead, use a complete four- or five-digit code that indicates that the diagnosis is "unspecified" (due to lack of complete documentation), or "other" if a more specific ICD-9 code is not available but the documentation states a specific diagnosis.

Example: A physician orders collagen crosslinks 82523 (Collagen crosslinks, any method) with a diagnosis of hyperparathyroidism. As of Oct. 1, Medicare will no longer pay for this test when ordered with 252.0 (Hyperparathyroidism) because the code is no longer valid under ICD-9 2005, and it is therefore not on the [...]