Pathology/Lab Coding Alert

Reimbursement for the acute hepatitis panel or individual hepatitis tests depends on assigning the proper procedural code(s) based on the laboratory methods used and antigen or antibody identified, as well as proper application of Medicare's coverage policies for medical necessity and frequency limits.
 
Although longstanding policy does not allow Medicare to cover tests performed in the absence of signs, symptoms or personal history of disease, hepatitis testing for asymptomatic patients may be covered for certain groups with risk of exposure to the illness, including certain patients undergoing transplants, transfusions or repeated dialysis.
 
Although CMS (formerly HCFA) has a proposed national coverage decision for the hepatitis panel, there is now no uniform policy for coverage of the panel or other hepatitis tests. "That means coders must be aware of a myriad of guidance for appropriate use of these tests, beginning with any local medical review policies (LMRPs) of their Medicare carrier or rules from third-party payers," says Stan Werner, MT (ASCP), administrative director and corporate compliance officer of Peterson Clinical Laboratory in Manhattan, Kan. 

 
Whether testing for hepatitis A, B or C, analyses fall into three main categories: antibody tests by various methods, antigen tests by enzyme immunoassay (EIA), or infectious agent tests by nucleic acid probe technique. "Assigning the proper procedure code for a hepatitis test involves knowing both the method of testing and the viral antigen or antibody identified," Werner says. "But the key to reimbursement for the tests is documentation of patient status that supports medical necessity for diagnosis or treatment of disease, not for screening."
 
Although specific coverage policies for individual hepatitis tests will vary by carrier or third-party payer, several diagnoses indicate medical necessity for hepatitis testing. These include patients diagnosed with HIV (042), viral hepatitis (070.0-070.9), liver disorders (570-573.9), jaundice (not of newborn, 782.4 ), repeat dialysis patients (585-586 and V45.1) and liver transplant patients (996.82 and V72.85).
 
"Despite the fact that LMRPs and third-party payer rules may vary for these tests, a general understanding of what each assay reveals about the patient's hepatitis infection or immunity status will help coders know when an ordered test is indicated," says Laurie Castillo, MA, CPC, CPC-H, CCS-P, a member of the National Advisory Board of the American Academy of Professional Coders. For example, it would be improper to run the hepatitis B test for infectivity on a patient who has not even been diagnosed with the disease.
 
"Although the treating physician orders the tests, Medicare's compliance guide charges laboratories with ensuring documentation of medical necessity for the tests they run," Castillo says. "Of course labs cannot tell physicians what tests to order, or which diagnosis codes to use, but they must educate physicians about medical- necessity guidelines and ensure that proper documentation is on file. If not, the lab should obtain an advance beneficiary notice (ABN) for the service so they can bill the patient directly if it is not covered."

 
A list of hepatitis A, B and C tests follows, including a brief description of names for the tests, the method involved and patient status that may indicate medical necessity (for specific coverage rules, contact your local Medicare carrier or third-party payers).

Antibody Tests
 
Antibody tests are qualitative or semiquantitative immunoassays by multiple-step methods, including radioimmunoassay (RIA), enzyme-linked immunosorbent assay (ELISA), enzyme immunoassay (EIA), immunoradiometric assay (IRMA), microparticle enzyme immunoassay (MEIA), or immunoenzymatic assay (IEMA).
 
Hepatitis B core antibody:
 

86704 (... antibody [HBcAb]; total) (IgG and IgM). Identifies patients with acute, chronic or past hepatitis B infection.
 

86705 (... IgM antibody). Presence indicates acute infection (evident in serum following hepatitis B surface antigen). Most Medicare carriers cover this test only when an acute hepatitis B infection is suspected based on clinical findings. If negative, a repeat test is indicated if symptoms persist, but not once positive. The test is unnecessary in the presence of a recently positive hepatitis B surface antigen or antibody. This test is part of the acute hepatitis panel.

 
Hepatitis B surface antibody:
 

86706 (... HBsAb). Presence indicates immunity due to previous infection or vaccination. Many Medicare carriers cover this test one to six months following medically necessary hepatitis B vaccination to affirm adequate antibody response. A low antibody titer indicates the need for repeat vaccination, followed by repeat HBsAb testing.
 
The test is also usually covered one month after diagnosis of acute hepatitis B infection. If HBsAb is not found, the test may be repeated monthly for up to six months while seeking the disappearance of the hepatitis B surface antigen, which indicates recovery. If HBsAg persists beyond six months and HBsAb remains absent, the patient is considered a chronic carrier, and no further HBsAb testing is warranted.
  
Hepatitis B envelope antibody:
 

86707 (... HBeAb).  Presence indicates likelihood of lower infectivity of hepatitis B carriers. Generally ordered only for chronically HBsAg-positive patients.

 
Hepatitis A antibody:
 

86708 (... [HAAb]; total) (IgG and IgM). Identifies patients with acute or past hepatitis A infection.
 

86709 (... IgM antibody). Presence indicates acute infectious disease. This test is included in the acute hepatitis panel.

 
Hepatitis C antibody:
 
Absent symptoms, the tests are indicated for patients with possible exposure to hepatitis C virus-infected blood (HCV) through donors who subsequently test positive for HCV. Once positive, repeat testing is unnecessary unless the patient receives anti-viral therapy.
 

86803 (hepatitis C antibody). Positive test indicates the likelihood of hepatitis C infection (past or current), but must be confirmed. This test is part of the acute hepatitis panel.
 

86804 (... confirmatory test). Used as a positive anti-hepatitis C titer, this test involves a method such as recombinant immunoblot assay (RIBA).

Antigen Tests
 
Antigen tests are multiple-step qualitative or semiquantitative by enzyme immunoassay tests:

 
Hepatitis B surface antigen:
 

87340 (... HBsAg). This test identifies a portion of the lipoprotein coating of the hepatitis B virus and is the earliest indicator of acute infection (followed by an elevated hepatitis B core antibody IgM). The failure of the surface antigen to be displaced by the surface antibody (HBsAb) after six months indicates a chronic infectious carrier state. Therefore, repeat testing is generally allowed for the surface antigen and antibody during the six-month window. The test is included in the acute hepatitis panel.
 

87341 (... [HBsAg] neutralization). This is a confirmatory test ordered following repeated positive results
beyond six months for 87340, which may indicate chronic hepatitis B infection.

 
Hepatitis B envelope antigen:
 

87350 (... HBeAg). The HBeAg is often allowed for patients with chronic HBsAg-positive results, as it is related to higher infectivity of hepatitis B carriers.

 
Unlike the previous hepatitis tests that are carried out only on blood specimens, these tests can be performed on liver tissue as well. The nucleic acid tests are used in some cases to monitor patients undergoing anti-viral therapy but are not generally used for diagnosis because  they are complex techniques, and not all are FDA-approved. Local coverage rules for these tests may vary, and some may not be covered.
 
Because the services for the direct and amplified probe techniques are included in the quantification service, Medicare allows only the quantification for the same patient on the same day. However, if the direct and amplified versions of a test are medically necessary and billed on the same day, Medicare allows both tests.

 
Hepatitis B virus:
 

87515 (... direct probe technique).
 

87516 (... amplified probe technique) with DNA amplified by polymerase chain reaction (PCR).
 

87517 (... quantification). This test may be ordered for patients already diagnosed with hepatitis B to monitor the course of treatment and chronic disease.

 
Hepatitis C virus (HCV RNA). Persistence of HCV RNA more than six months beyond initial infection indicates chronic disease.
 

87520 -- Direct probe technique.
 

87521 -- Amplified probe technique, with RNA amplified by reverse transcription polymerase chain reaction (RT-PCR). Positive results on this test, perhaps accompanied by elevated blood levels of alanine aminotransferase (ALT), indicate active infection.
 

87522 (... quantification). This test is not used for diagnosis of infection but may be used to monitor treatment of patients with hepatitis C.

 
This panel includes tests to screen for acute hepatitis infection, including hepatitis A antibody IgM (86709), hepatitis B core antibody IgM (86705), hepatitis B surface antigen (87340) and hepatitis C antibody (86803). "When these tests are conducted together, individual tests should not be coded separately but should be reported as one unit of 80074," Werner says. "Any additional hepatitis tests ordered should be reported in addition to the panel code."
 
CMS' coverage indications and limits for the hepatitis panel are outlined in the proposed national coverage decision published in the March 10, 2000, Federal Register, which is online at www.access.gpo.gov.
 
The panel is indicated to detect viral hepatitis in patients with abnormal liver function tests and/or signs or symptoms of hepatitis. If the hepatitis panel is negative but symptoms of liver disease persist, a repeat panel may be ordered because the time of exposure and stage of disease may have resulted in a false negative. According to the proposed rule, other indications for the hepatitis panel include pre- and post-liver transplant testing. LMRPs for the hepatitis panel often include an extensive list of covered ICD-9 codes, which can be obtained from your carrier or accessed on the Internet at www.lmrp.net.

 
Most hepatitis tests are conducted on serum specimens, with the blood obtained by fingerstick or venipuncture. "When the specimen is taken at the laboratory, the collection service is separately billable as 36415 (routine venipuncture or finger/heel/ear stick for collection of specimen[s]) or G0001 (routine venipuncture for collection of specimen[s]) for Medicare patients," Castillo says.
 
If the specimen is liver tissue, it must be obtained by liver biopsy. The pathologist's service for evaluation of the surgical specimen is reported as 88307 (level V - surgical pathology, gross and microscopic examination; liver, biopsy - needle/wedge). Any hepatitis tests ordered on the biopsy are reported in addition to the surgical pathology service.