Pathology/Lab Coding Alert

HCFA has temporarily suspended many of the edits in version 6.3 of the national Correct Coding Initiative (CCI). These edits bundled 66 evaluation and management (E/M) services to more than 50 pathology and laboratory procedural codes. The suspension, issued Jan. 26, affects many of the 3,500 edits and is retroactive to Oct. 30, 2000, the date the 6.3 edits were issued.

Most significant about the 6.3 edits was the bundling of E/M services with diagnostic procedures a decision that took many physicians and coders by surprise, says Barbara Cobuzzi, CPC, CHBME, president of Cash Flow Solutions Inc. in Lakewood, N.J. The changes were not adequately publicized and placed a financial burden on those who were suddenly receiving denials for previously covered procedures, she says. Claims denied under the 6.3 edits should be resubmitted for adjustment with modifier -25 (significant, separately identifiable evaluation and management service by the same physician on same day of the procedure or other service) appended to the E/M service if the service meets the separate and significant criteria. In deciding which claims may qualify, physicians and coders should look to the explanation of medical benefits on the insurance form. It will indicate that the claim was denied or reduced because either the service was not significant or separately identifiable or payment was included in another service received on the same day.

Impact on Pathology Coding

The pathology edit pairs suspended by HCFA include bundling of E/M services with evocative/suppression and other laboratory tests, certain anatomic pathology codes and some blood banking and transfusion medicine codes.

The primary problem with the bundling arises when E/M services and a diagnostic lab or pathology service are reported by the same facility for the same patient on the same day, says Laurie Castillo, MA, CPC, CPC-H, CCS-P, member of the National Advisory Board of the American Academy of Professional Coders. For example, if a hospital emergency department and hospital laboratory billed for the E/M and lab service under the CCI version 6.3 edits , they would have had to use modifier -25 for both services to be reimbursed. Similarly, if a patient is seen at a hospital-owned clinic and has lab work done by the hospital lab, the services would have been subject to these edits, Castillo says. Unless or until these edits are put back in place, hospitals wont need to use modifier -25 in these cases.

However, the suspension of CCI version 6.3 will not impact coding for many independent pathology practices, says R.M. Stainton Jr., MD, president of Doctors Anatomic Pathology Services, an independent pathology laboratory in Jonesboro, Ark. Many of these [...]