Pathology/Lab Coding Alert

Medicare Adds Hematology and Consultation Edits


If you report hematology or "consultation on referred material" procedures for your lab, get ready to learn when you can and can't use a modifier to get paid for multiple services. National Correct Coding Initiative (NCCI) edits, version 9.2, effective July1, both open and close some coding loopholes for reporting newly bundled services.  You Can Report Bundled Codes Together Sometimes  Medicare pairs procedures into NCCI Edits to indicate that the services are either bundled or not normally performed together. "If a physician carries out two medically necessary, distinct services of an NCCI code pair, Medicare may pay for both procedures if you report them with the appropriate modifier," says William Dettwyler, MT-AMT, coding analyst for Health Systems Concepts, a laboratory coding and compliance consulting firm in Longwood, Fla. 
 
"To indicate that codes represent separate services as opposed to unbundling, append modifier -59 (Distinct procedural service) to override the edit," Dettwyler says. For clinical lab tests conducted more than once a day, use modifier -91 (Repeat clinical diagnostic laboratory test). You can only override an NCCI edit with a modifier if the code pair shows a "1" in the modifier indicator column. A "0" modifier indicator means that you cannot override the edit pair. Hematology Includes Second Look  When automated blood counts return results that require the lab to look more carefully at the blood smear or differential, can you report that "second look"? Medicare made it clear in NCCI edits prior to 9.2 that you cannot report a manual differential (85007, Blood count; blood smear, microscopic examination with manual differential WBC count) with a complete CBC and automated differential (85025, Blood count; complete [CBC], automated [Hgb, Hct, RBC, WBC and platelet count] and automated differential WBC count). In other words, if your automated CBC and differential reflexes to a manual diff, you can't report the second differential as an additional service.

 "Medicare's stance is that you have to perform the second differential to accomplish what the doctor ordered it's part of the 85025 service," Dettwyler says.
 
Following the same logic, Medicare added new edit pairs in NCCI 9.2 that disallow reporting a more in-depth (microscopic) exam of the blood smear as a separate hematology service. Medicare now pairs 85008 (Blood count; blood smear, microscopic examination without manual differential WBC count) with the following hematology codes:
 
 85004 Blood count; automated differential WBC count
   85025 Blood count; complete (CBC), automated (Hgb, Hct, RBC, WBC and platelet count) and automated differential WBC count
   85027 ...; complete (CBC), automated (Hgb, Hct, RBC, WBC and platelet [...]