Pathology/Lab Coding Alert

Unbundling breaking down a single procedure into its component parts and billing for additional services is a major compliance problem. Unfortunately, many physicians dont understand this concept, which can lead to claim denials. By reviewing the basic ideas behind bundling, such as component and comprehensive codes, pathologists can avoid such problems.

By far the largest source of bundling combinations, or edits, is Medicares national Correct Coding Initiative (CCI), which has developed coding policies and more than 120,000 edits for reimbursement compliance to better control improper coding.

Although the CCI has been in place since Jan. 1, 1996, many pathologists still do not understand its impact on how they bill procedures. This has serious compliance consequences because Medicare auditors may construe billing for procedures bundled into others as fraud.

Mutually Exclusive Codes

The CCI is particularly important to pathologists because the billing for many of the procedures they perform is guided by its policies. Approximately 11,000, or just less than 10 percent, of the CCIs 120,000 edits are categorized as mutually exclusive. These code pairs describe tests that would not reasonably be performed for the same patient by the same physician on the same day.

For example, blood counts that measure similar parameters but use different laboratory methodology would not be conducted together. That is why 85023 (blood count; hemogram and platelet count, automated, and manual differential WBC count [CBC]) should not be reported with 85025 (blood count; hemogram and platelet count, automated, and automated complete differential WBC count [CBC]). The code that most accurately describes the methodology used should be reported. Mutually exclusive codes are not considered bundled, but they do represent codes that should not be reported together.

Component and Comprehensive Codes

Most CCI edits, about 90 percent of them, may be categorized roughly as bundles comprehensive codes that include component codes. Physicians may not bill the component codes if they also charge for the comprehensive procedure.

For example, the service for code 88329 (pathology consultation during surgery) is included in the service for 88331 (pathology consultation during surgery; with frozen section[s], single specimen). Listing both 88329 and 88331 for a single consultation with frozen section would be considered unbundling of services.

CCI further subdivides the comprehensive/component code category according to principles used to determine the edit. These principles include:

1. CPT Definition. Some CPT Codes are part of a series in which the first code becomes a component for the codes that follow it because they refer back to the common portion of the procedure listed in the first code. This relationship is indicated in the CPT manual by the convention of indentation and semicolon. It states, The indented code refers back to a common portion of the procedure (that part before the semicolon) listed in a preceding entry.

For example, the therapeutic drug assay for procainamide, 80190 (procainamide), is followed by the indented code 80192 (procainamide; with metabolites [e.g., n-acetyl procainamide]). If the lab performs the more specific assay that includes metabolites, then only 80192 would be reported because the 80190 procedure is a component of it.

2. CPT Manual Instructions/Guidelines. CPT also gives bundling instructions at the beginning of some sections in the manual. For example, in the introduction to the series of codes 87260-87999, it states, Infectious agents by antigen detection, direct fluorescence microscopy, or nucleic acid probe techniques should be reported as precisely as possible. The most specific code possible should be reported.

In this sense, 87260 (infectious agent antigen detection by direct fluorescent antibody technique; adenovirus) is a comprehensive code, of which 87206 (smear, primary source, with interpretation; fluorescent and/or acid fast stain for bacteria, fungi, or cell types) is a component. In other words, 87260 reports the specific method of using fluorescent antibody stain to detect the adenovirus antigen. This includes the more generic service that is described by code 87206. The comprehensive, more precise code should be reported, rather than the less specific component code.

3. Sequential Procedures. Sometimes pathologists begin with a more general procedure and then continue on to a more specific procedure in the same session. In this case, the tests are considered sequential, and the more specific procedure should be reported.

For example, when a screening for cold agglutinin (86156, cold agglutinin; screen) is positive, it often may be followed by a titer in the same session (86157, cold agglutinin; titer). These tests are considered sequential, and the more specific titer code, 86157, which gives quantitative information, should be reported. Again, the CPT manual gives an indication of the component/comprehensive relationship by the use of the semicolon and indentation.

4. Most Extensive Procedures. If a primary-care physician requests that a pathologist consult on a clinical laboratory test by reviewing the test results to render a medical judgment and report, the pathologist would code 80500 (clinical pathology consultation; limited, without review of patients history and medical records). If, on the other hand, the pathologist also reviews the patients medical history and records and provides medical interpretive judgment and report in that context, code 80502 (clinical pathology consultation; comprehensive, for a complex diagnostic problem, with review of patients history and medical records). Code 80502 represents the comprehensive, most extensive procedure, which includes the component of 80500. Both codes should not be reported together.

5. With vs. Without Procedures. The only difference between 81000 (urinalysis, by dip stick or tablet reagent for ; non-automated, with microscopy) and 81002 (urinalysis, by dip stick or tablet reagent for ; non-automated, without microscopy) is that 81002 does not include microscopy. Therefore, billing for both codes at the same time would be inappropriate. The service for 81002 is considered a component of 81000.

6. Standards of Medical/Surgical Practice. For example, a blood glucose test using a reagent strip, 82948 (glucose; blood, reagent strip), typically is performed as part of the more exhaustive glucose tolerance test, 82951 (glucose; tolerance test [GTT], three specimens [includes glucose]). Therefore, if a glucose tolerance test with three specimens is carried out, 82951 should be reported, but the reagent strip should be included without reporting a separate code.

7. Laboratory Panels. In the CPT manual, each laboratory panel code (80048-80090) includes a listing of the individual tests that comprise the panel. Do not report both the panel and one or more of its component tests together because that is duplicate reporting. For example, triglycerides (84478) should not be reported in addition to the lipid panel (80061). The actual service performed should be reported, whether that is the panel or the individual test. Note that if a panel service is provided you must be able to prove medical necessity for each component test.

There are three other subcategories codes listed in CPT as a separate procedure, anesthesia included in surgical procedures, and designation of sex procedures by which component codes are bundled into comprehensive procedures, but these are not common to pathology practices.

Judiciously Use Modifiers That Override Bundles

Modifiers to indicate that distinct or independent procedures were performed may override most CCI edits. When special circumstances result in two different services being provided, billing with two codes that normally would be bundled is appropriate. The special circumstances usually entail procedures carried out on separate body sites or during different times of the same day. Payers say that they would expect these circumstances to be rare.

Modifier -59 (distinct procedural service) was created as a response to the CCI edits and can override most, but not all, bundling combinations. The CCI uses indicators to show which codes appropriately may use modifier -59 if documentation exists to support the claim that the procedures were distinct and independent.

Medicare also has developed its own HCPCS modifiers to indicate that procedures were performed on different sites on the body. These include -LT (left side), used to identify procedures performed on the left side of the body, -RT (right side), and -TA through -T9 (toes).

Whether normally bundled codes can be reported together using modifiers under appropriate circumstances is indicated by the presence of a superscript number next to the codes in the CCI edit list. If the codes can be modified, they will have an indicator (1) beside them in the CCI. If they cant, indicator (0) is shown. Most of the mutually exclusive codes cannot be modified.

Pathologists may bill many of the edits in the comprehensive/component category and its subcategories using modifier -59 when appropriate. They should keep in mind that using modifier -59 sends up a red flag for audit, however, so it should be used carefully and discriminately after ensuring that the appropriate documentation exists to back up the claim.

Although the Correct Coding Initiative is important, it is not the only group of coding edits that Medicare uses. The Health Care Financing Administration (HCFA) instituted many edits before the CCI was established in 1996 and still enforces these. In addition, HCFA purchased a series of edits from HBO&C, which the agency refers to as commercial or proprietary edits and the rest of the coding world knows as black box edits because they are not published anywhere due to their proprietary nature.

Finally, pathologists should remember that commercial carriers are not bound by and do not necessary follow the CCI, though they may use it selectively. Individual payers should be contacted for their specific edit rules.

Note: For information about CCI edits, contact the provider relations staff of your local Medicare carrier. The National Technical Information Service (NTIS) publishes the CCI edits, along with several other commercial resellers who purchase the raw data from NTIS. The edits can be purchased from any of the vendors.

Editors note: This article was prepared with the help of Garnet Dunston, CPC, MPC, president of Dunston Enterprises, a coding and consulting firm in Phoenix, and Susan Callaway-Stradley, CPC, CCS-P, an independent coding specialist and educator in North Augusta, S.C.