Coding Essentials for Laboratories 2018 An Easy-to-Use Tool for Coding and Reimbursement Compliance Prepared and Published By: MedLearn Publishing A Division of MedLearn Media, Inc. 445 Minnesota Street, Suite 514 St. Paul, MN 55101 1-800-252-1578 medlearnmedia.com
Introduction... 1 New Way of Thinking...1 Future of Reimbursement...2 CPT Coding Guidelines...3 CPT Terminology Format...5 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 System...27 Stay Informed...28 CLIA Compliance...28 Medicare Packaging of Lab Tests...28 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 2018...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...39 Coding Changes for 2018...41 Chapter 3: Therapeutic Drug Assays... 43 Multiple Tests...43 Unlisted Tests...44 Billing and Coding Tips...45 Coding Changes for 2018...46 Chapter 4: Urinalysis... 47 Routine Urinalysis...47 Other Urinalysis...48 Coding Flowchart...49 Billing and Coding Tips...50 Coding Changes for 2018...51 Chapter 5: Molecular Pathology... 53 Tier 1/Tier 2...53 Geonomic Sequencing Procedures and Other Molecular Analyte Assays...55 ii
Multianalyte Algorithmic Assay...55 Proprietary Laboratory Analyses...56 Professional Interpretation...56 14-Day Rule and Date of Service...57 Payment...58 Coding Changes for 2018...59 Chapter 6: Chemistry Testing... 85 Custom Profiles and Panels...85 Comprehensive Codes...85 When the Specimen Matters...86 When the Method Matters...86 Frequency Limits and Overutilization...87 Example: Blood Glucose Testing...88 Billing and Coding Tips...89 Coding Changes for 2018...90 Chapter 7: Hematology... 91 Standardized Chargemaster for Multisite Facilities...91 Customizing Test Descriptions...91 Chargemaster-Driven Overutilization...92 Compliance Issues...92 Reflex Testing vs. Quality Assurance...92 Prescription Pad Orders...93 Coding Flowchart...95 Billing and Coding Tips...96 Coding Changes for 2018...96 Chapter 8: Coagulation Testing... 97 Custom Profiles and Panels...97 Medical Necessity Versus Screening...97 Standing Orders Versus Recurring Orders...97 Frequency Limits and Overutilization...98 Coding Flowchart...99 Billing and Coding Tips...99 iii
Coding Changes for 2018...100 Chapter 9: Immunology... 101 Compliance Issues...102 Reflex Testing...102 NCCI and Medically Unlikely Edits...102 Authoritative Resources...103 Billing and Coding Tips...104 Coding Changes for 2018...105 Chapter 10: Microbiology... 107 Matching Order Options to the Chargemaster...107 Submitting Follow-up Test Codes...108 Culture of Pathogen and Detection of Infectious Agent...109 Infectious Antigen Detection...111 To Recap the Issues...112 Coding Flowchart...115 Billing and Coding Tips...115 Coding Changes for 2018...117 Chapter 11: Blood Banking and Transfusion Medicine... 119 Billing for the Blood Product...119 Crossmatch Codes...122 Retyping the Units...122 Code Assignment for Transfusion Medicine Services...123 Blood Transfusions...127 Billing and Coding Tips...128 Coding Changes for 2018...129 Chapter 12: Cytopathology... 131 Non-Gynecological Specimens...131 CPT/HCPCS Codes...131 Intended Use of Codes...132 Billing and Coding Tips...133 Gynecological Specimens...134 iv
CPT/HCPCS Codes...134 Intended Use of Codes...135 Billing and Coding Tips...141 Coding Changes for 2018...141 Fine Needle Aspirate...142 CPT/HCPCS Codes...142 Intended Use of Codes...142 Billing and Coding Tips...142 Coding Changes for 2018...143 Flow Cytometry...143 CPT/HCPCS Codes...143 Billing and Coding Tips...144 Coding Changes for 2018...145 Chapter 13: Cytogenetic Studies... 147 Coding Flowchart...150 Billing and Coding Tips...151 Coding Changes for 2018...151 Chapter 14: Surgical Pathology and Histology... 153 Outpatient Payment and APCs...154 Unit of Service...154 Date of Service Rules for Histology...155 Specimen Processing, Special Stains and Other Related Procedures...155 Billing and Coding Tips...157 Frozen Section...158 CPT/HCPCS Codes...158 Intended Use of Codes...158 Billing and Coding Tips...158 Touch Prep...159 CPT/HCPCS Codes...159 Intended Use of Codes...159 Billing and Coding Tips...159 Antibody Techniques...160 CPT/HCPCS Codes...160 v
Intended Use of Codes...160 Billing and Coding Tips...161 Bone Marrow Studies...161 Prostate Biopsy Mapping Specimens...162 Morphometric Analysis...163 CPT/HCPCS Codes...163 Intended Use of Codes...163 Billing and Coding Tips...164 Nerve Teasing...164 CPT/HCPCS Codes...164 Intended Use of Codes...164 Billing and Coding Tips...164 In situ Hybridization...165 CPT/HCPCS Codes...165 Intended Use of Codes...165 Billing and Coding Tips...166 Protein Analysis of Tissue by Western Blot...166 CPT/HCPCS Codes...166 Intended Use of Codes...167 Billing and Coding Tips...167 Dissection and Microdissection Procedures...167 CPT/HCPCS Codes...167 Intended Use of Codes...168 Billing and Coding Tips...168 Postmortem Examination...169 CPT/HCPCS Codes...169 Intended Use of Codes...169 Billing and Coding Tips...170 Coding Changes for 2018...170 Chapter 15: In Vivo (Transcutaneous) Procedures, Miscellaneous Testing, Reproductive Medicine... 171 Handling or Shipping Fees...171 In Vivo (Transcutaneous) Procedures...172 vi
Specimen Collection (Venipunctures, Finger-sticks and Arterial Punctures)...172 Travel Allowance...174 Billing and Coding Tips...175 Coding Changes for 2018...175 Chapter 16: Preventive Screening Procedures... 177 Prostate Antigen Screening for Adenocarcinoma...177 Fecal Occult Blood Screening for Colorectal Cancer...178 Measurement of Lipid Levels to Screen for Cardiovascular Disease...179 Diabetes Screening...180 Human Immunodeficiency Virus...182 Sexually Transmitted Infections (STIs)...184 Hepatitis C Virus Screening...186 Billing and Coding Tips...187 Chapter 17: Payment Methods for Clinical Laboratory and Professional Services... 189 Pathology Payment Methods...190 Column 1: HCPCS...190 Column 2: Mod (Modifier)...190 Column 3: MPFS Status Code...191 Column 4: MPFS PC/TC Indicator...191 Column 5: MPFS Work RVU...193 Column 6: MPFS Facility RVU...193 Column 7: Non-Facility RVU...193 Column 8: MPFS Conversion Factor...193 Column 9: OPPS Status Indicator...193 Column 10: OPPS APC Rate...194 Column 11: CLFS 2018 Payment...194 Clinical Pathology Consultations...240 Consultations on Referred Material...241 Appendix A: Medicare Manuals... 243 vii
Appendix B: Medicare Quality Payment Programs... 263 MACRA...264 MIPS...264 Advanced APMs...265 Tips for Quality Compliance...265 viii