Coding Essentials for Laboratories 2017 An Easy-to-Use Tool for Coding and Reimbursement Compliance Prepared and Published By: MedLearn Publishing A Division of Panacea Healthcare Solutions, Inc. 287 East Sixth Street, Suite 400 St. Paul, MN 55101 1-800-252-1578 panaceainc.com
Introduction... 1 New Way of Thinking...1 Future of Reimbursement...2 CPT Coding Guidelines...3 CPT Terminology Format...4 Coding Flowcharts...5 Quantitative vs. Qualitative...5 Specimen Codes...6 Each Specimen or Each Analyte...7 Free and Total Studies...8 Only and Screen Tests...9 Each Antigen or Each Antibody...10 Antigens or Antibodies...11 With or Without Studies...11 In Addition Studies...12 Category III CPT Codes...12 HCPCS Alternate Codes...13 Revenue Center Codes...14 Modifiers...15 National Correct Coding Initiative...19 Procedure-to-Procedure Edits...20 Add-on Edits...21 Medically Unlikely Edits...22 Other Coding Guidance...23 National Coverage Determinations...23 Local Coverage Determinations...25 Routine Screening Tests...25 Reasonable and Necessary Denials...26 Frequency Limits...26 Tests Not Ordered by Qualified Provider...26 Diagnosis Coding Guidelines for Labs...26 ICD-10 Coding Primer...27 The ICD-10 Coding System...28 Stay Informed...29 CLIA Compliance...29 Medicare Packaging of Lab Tests...29 i
Chapter 1: Organ and Disease Panels... 31 Standard and Custom Panels...31 Screening Tests...31 Duplicate Billing...32 ESRD Composite Rate Billing...32 Organ or Disease-Oriented Panels...33 Billing and Coding Tips...33 Coding Changes for 2017...34 Chapter 2: Drug Testing... 35 Drugs of Abuse Analysis...35 Presumptive Drug Analysis...36 Reporting of Presumptive Drug Analysis...36 Definitive Drug Analysis...37 Reporting of Definitive Drug Analysis...37 Opioids and Opiate Analogs...38 Billing and Coding Tips...40 Coding Changes for 2017...41 Chapter 3: Therapeutic Drug Assays... 43 Multiple Tests...43 Unlisted Tests...44 Billing and Coding Tips...45 Coding Changes for 2017...46 Chapter 4: Urinalysis... 47 Routine Urinalysis...47 Other Urinalysis...48 Coding Flowchart...49 Billing and Coding Tips...50 Coding Changes for 2017...51 Chapter 5: Molecular Pathology... 53 Professional Interpretation...55 Geonomic Sequencing Procedures and Other Molecular Analyte Assays...55 Multianalyte Algorithmic Assay...56 ii
Payment...57 Coding Changes for 2017...58 Chapter 6: Chemistry Testing... 71 Custom Profiles and Panels...71 Comprehensive Codes...71 When the Specimen Matters...72 When the Method Matters...72 Frequency Limits and Overutilization...73 Example: Blood Glucose Testing...74 Billing and Coding Tips...75 Coding Changes for 2017...76 Chapter 7: Hematology... 77 Standardized Chargemaster for Multisite Facilities...77 Customizing Test Descriptions...77 Chargemaster-Driven Overutilization...78 Compliance Issues...78 Reflex Testing vs. Quality Assurance...78 Prescription Pad Orders...79 Coding Flowchart...81 Billing and Coding Tips...82 Coding Changes for 2017...82 Chapter 8: Coagulation Testing... 83 Custom Profiles and Panels...83 Medical Necessity Versus Screening...83 Standing Orders Versus Recurring Orders...83 Frequency Limits and Overutilization...84 Coding Flowchart...85 Billing and Coding Tips...85 Coding Changes for 2017...86 Chapter 9: Immunology... 87 Compliance Issues...88 Reflex Testing...88 iii
NCCI and Medically Unlikely Edits...88 Authoritative Resources...89 Billing and Coding Tips...90 Coding Changes for 2017...91 Chapter 10: Microbiology... 93 Matching the Requisition to the Chargemaster...93 Submitting Follow-up Test Codes...94 Culture of Pathogen and Detection of Infectious Agent...95 Infectious Antigen Detection...97 To Recap the Issues...98 Coding Flowchart...101 Billing and Coding Tips...101 Coding Changes for 2017...103 Chapter 11: Blood Banking and Transfusion Medicine... 105 Billing for the Blood Product...105 Crossmatch Codes...108 Retyping the Units...108 Code Assignment for Transfusion Medicine Services...109 Blood Transfusions...113 Billing and Coding Tips...114 Coding Changes for 2017...115 Chapter 12: Cytopathology... 117 Non-Gynecological Specimens...117 CPT/HCPCS Codes...117 Intended Use of Codes...118 Billing and Coding Tips...119 Gynecological Specimens...120 CPT/HCPCS Codes...120 Intended Use of Codes...121 Billing and Coding Tips...127 Coding Changes for 2017...127 Fine Needle Aspirate...127 iv
CPT/HCPCS Codes...127 Intended Use of Codes...128 Billing and Coding Tips...128 Coding Changes for 2017...129 Flow Cytometry...129 CPT/HCPCS Codes...129 Billing and Coding Tips...130 Coding Changes for 2017...131 Chapter 13: Cytogenetic Studies... 133 Coding Flowchart...136 Billing and Coding Tips...137 Coding Changes for 2017...137 Chapter 14: Surgical Pathology and Histology... 139 Outpatient Payment and APCs...140 Unit of Service...140 Date of Service Rules for Histology...141 Specimen Processing, Special Stains and Other Related Procedures...141 Billing and Coding Tips...143 Frozen Section...144 CPT/HCPCS Codes...144 Intended Use of Codes...144 Billing and Coding Tips...145 Touch Prep...145 CPT/HCPCS Codes...145 Intended Use of Codes...145 Billing and Coding Tips...145 Antibody Techniques...146 CPT/HCPCS Codes...146 Intended Use of Codes...146 Billing and Coding Tips...147 Bone Marrow Studies...147 Prostate Biopsy Mapping Specimens...148 Morphometric Analysis...149 v
CPT/HCPCS Codes...149 Intended Use of Codes...149 Billing and Coding Tips...150 Nerve Teasing...150 CPT/HCPCS Codes...150 Intended Use of Codes...150 Billing and Coding Tips...150 In situ Hybridization...151 CPT/HCPCS Codes...151 Intended Use of Codes...151 Billing and Coding Tips...152 Protein Analysis of Tissue by Western Blot...152 CPT/HCPCS Codes...152 Intended Use of Codes...153 Billing and Coding Tips...153 Dissection and Microdissection Procedures...153 CPT/HCPCS Codes...153 Intended Use of Codes...154 Billing and Coding Tips...154 Postmortem Examination...155 CPT/HCPCS Codes...155 Intended Use of Codes...155 Billing and Coding Tips...156 Coding Changes for 2017...156 vi
Chapter 15: In Vivo (Transcutaneous) Procedures, Miscellaneous Testing, Reproductive Medicine... 157 Handling or Shipping Fees...157 In Vivo (Transcutaneous) Procedures...158 Specimen Collection (Venipunctures, Finger-sticks and Arterial Punctures)...158 Travel Allowance...160 Billing and Coding Tips...161 Coding Changes for 2017...161 Chapter 16: Preventive Screening Procedures... 163 Prostate Antigen Screening for Adenocarcinoma...163 Fecal Occult Blood Screening for Colorectal Cancer...164 Measurement of Lipid Levels to Screen for Cardiovascular Disease...165 Diabetes Screening...166 Human Immunodeficiency Virus...168 Sexually Transmitted Infections (STIs)...170 Hepatitis C Virus Screening...172 Billing and Coding Tips...173 Chapter 17: Payment Methods for Clinical Laboratory and Professional Services... 175 Pathology Payment Methods...176 Column 1: HCPCS...176 Column 2: Mod (Modifier)...176 Column 3: MPFS Status Code...177 Column 4: MPFS PC/TC Indicator...177 Column 5: MPFS Work RVU...179 Column 6: MPFS Facility RVU...179 Column 7: Non-Facility RVU...179 Column 8: MPFS Conversion Factor...179 Column 9: OPPS Status Indicator...179 Column 10: OPPS APC Rate...180 Column 11: CLFS National Limit...180 vii
Clinical Pathology Consultations...226 Consultations on Referred Material...226 Appendix A: Medicare Manuals... 229 Appendix B: Medicare Quality Payment Programs... 249 Hospital IQR Program...249 Hospital OQR Program...250 Beyond the IQR and OQR Programs...251 viii