Pathology/Lab Coding Alert

AMA assigns codes for Borrelia tests and more.

Even if you're just getting the hang of the new Proprietary Laboratory Analyses (PLA) pathology section in CPT^® 2018, you can't stop there.

Each quarter, the AMA intends to release new codes for the section, and that starts with 10 new codes effective April 1.

What they are: PLA codes are alpha-numeric codes assigned by the AMA CPT^® Editorial Panel that list the proprietary clinical laboratory/manufacturer name. Each code describes a unique test that a single ("sole-source") laboratory provides, or that the manufacturer may license and market to multiple providing laboratories based on a process such as FDA clearance or approval. The lab or manufacturer applies for the PLA code, and the AMA releases new codes quarterly.

PLAs may be Advanced Diagnostic Laboratory Tests (ADLTs) or Clinical Diagnostic Laboratory Tests (CDLTs) as defined under the Protecting Access to Medicare Act of 2014 (PAMA). Many of the codes may be for multianalyte assays with algorithmic analyses (MAAAs) or genomic sequencing procedures (GSPs), but the PLA codes can include other types of medical laboratory tests.

Check Out New Codes

Effective April 1, you'll have 10 new PLA codes with the following numbers (listing proprietary name and lab):

• 0035U - Real-time quaking-induced conversion for prion detection (RT-QuIC), by National Prion Disease Pathology Surveillance Center
• 0036U - EXaCT-1 Whole Exome Testing, by Lab of Oncology-Molecular Detection at Weill Cornell Medicine-Clinical Genomics Laboratory
• 0037U - FoundationOne CDx™ (F1CDx), by Foundation Medicine, Inc.
• 0038U - SensievaTM Droplet 25OH Vitamin D2/D3 Microvolume LC/MS Assay, by InSource Diagnostics
• 0039U - Anti-dsDNA, High Salt/Avidity, by University of Washington, Department of Laboratory Medicine, Bio-Rad
• 0040U - MRDx BCR-ABL Test, by MolecularMD
• Four new tests for tick-borne illnesses by IGeneX Inc:​

         o 0041U - Lyme ImmunoBlot IgM, ID FISH Technology Inc. or (ASR) (Lyme ImmunoBlot IgM Strips Only)
         o 0042U - Lyme ImmunoBlot IgG, ID-FISH Technology Inc. (ASR) (Lyme ImmunoBlot IgG Strips Only)
         o 0043U - Tick-Borne Relapsing Fever (TBRF), Borrelia ImmunoBlots IgM Test, ID-FISH Technology Inc. (Provides TBRF ImmunoBlot IgM Strips)
         o 0044U - Tick-Borne Relapsing Fever (TBRF), Borrelia ImmunoBlots IgG Test, ID-FISH Technology Inc. (Provides TBRF ImmunoBlot IgG Strips).

Understand Coding Hierarchy

With the introduction of the PLA codes, labs have a clearer coding system for tracking use of specific, newer tests that might not otherwise have a code. Alternately, without the PLA codes, CMS might assign newer tests a HCPCS Level II code that many payers other than Medicare won't recognize.

Benefits: The AMA process for creating a Category 1 CPT^® code is more exacting and may take about 18 months to complete, while the PLA application process is more streamlined and may result in a new code in about three months, with quarterly release of new codes.

Where you'll find them: The AMA publishes the PLA codes in the CPT^® code set in a subsection at the end of the Pathology/Laboratory section. According to CPT^® 2018 Errata, "All [PLA] codes ... are also included in Appendix O, with the procedure's proprietary name." You can also find the codes, including the quarterly updates, on the AMA website at www.ama-assn.org/practice-management/cpt-pla-codes.

How to use them: To report a PLA code, the test must match both the code descriptor and the specific proprietary clinical lab or manufacturer. If a PLA code exists that describes a specific lab test, you must use that code. "The PLA code takes precedence over any other code that describes the test, even a Category I code," says William Dettwyler, MTAMT, president of Codus Medicus, a laboratory coding consulting firm in Salem, Ore.

In some cases, multiple PLA codes may have the identical code descriptor and be differentiated only by the proprietary name, which you'll have to use to assign the correct code. You'll see those codes indicated with the symbol, "i."

For instance: 0007U (ToxProtect by Genotox Laboratories LTD) and 0020U (ToxLok by InSource Diagnostics) both have the descriptor: Drug test(s), presumptive, with definitive confirmation of positive results, any number of drug classes, urine, includes specimen verification including DNA authentication in comparison to buccal DNA, per date of service.

If you're billing for a lab test that does not have a CPT^® Category I, Category III, MAAA Administrative code (also from Appendix O), or PLA code, you should assign the appropriate "unlisted" code, such as 81479 (Unlisted molecular pathology procedure) or 81599 (Unlisted multianalyte assay with algorithmic analysis).