Pathology/Lab Coding Alert

Understanding columns and modifiers can save you $$$

Want a handy list of the edit pairs discussed in " NCCI 10.2 Update: Get the Scoop on Infectious Agent Bundling," on page 65? Then check out the chart below for a list of the latest infectious agent code bundles.

But that's not all you'll find in this chart. You can also use the table to learn whether the edits are mutually exclusive (ME) or column 1/column 2 (C1/C2) code pairs, or if NCCI assigns a "0" or "1" modifier indicator for each edit pair. If your lab ever performs the more expensive procedure of an edit pair -- or perhaps both procedures -- you'll have to understand the information on this chart to collect for the service.

Mutually Exclusive Column 1 Code Pays Less

In the NCCI's ME edits section, you'll find procedures that a provider could not reasonably perform during the same session as one another. For example, the chart shows two ME lab tests that identify giardia by two different methods (87269, 87329) -- the lab would perform one method or the other on a given specimen, but not both.

Hidden Trap: If you report two ME codes together without a modifier, Medicare will pay for the column 1 code, which, according to NCCI instruction, "generally represents the procedure or service with the lower work RVU [relative value unit]."

"If you don't want to get stuck with the lower payment rate by default, you should ensure that you accurately report only one code for a given lab service," says Laurie Castillo, MA, CPC, CPC-H, CCS-P, president of Castillo Consulting in Manassas, Va.

For C1/C2 edit pairs, the column 1 code usually represents the more comprehensive and more expensive procedure - meaning that missing an edit pair for these codes may not be quite as costly as for an ME code pair.

Loophole: If the lab performs two separate tests on two separate specimens, you may be able to override the edit pair by appending modifier -59 (Distinct procedural service) to the column 2 code. For instance, the physician may order a serum cytomegalovirus (CMV) using DNA direct probe technique (87495), and on the same day may order a CMV test on a bronchoalveolar lavage (BAL) specimen that the lab processes using direct fluorescence antibody (DFA) technique. You should report 87495 and 87271-59 for these services.

Watch Out for Modifier Column

NCCI designates a "modifier indicator" for each edit pair, which appears in the last column of the chart. The indicators are "1," which means that you can use a modifier with the code pair when appropriate; "0," which means that you are not allowed to use a modifier with the code pair; and "9," which occurs only for code pairs that NCCI deleted retroactive to the effective date (you can ignore the bundles with the "9" indicator).

Snag: You cannot override an edit pair that has a "0" modifier indicator under any circumstances.