Neurology & Pain Management Coding Alert

Question: Our physician sometimes performs a MILD procedure at the hospital and sends the patients to a lab. Their work-up includes tests covered by codes 85025, 85610, and 85730. The lab needs a diagnosis supporting the tests that Medicare will accept -- but a "pre-procedure" diagnosis doesn't work. What do you recommend?

Mississippi Subscriber

Answer: Your first step is to determine whether the patients have any medical conditions that warrant the labs (such as V58.61, Long-term [current] use of anticoagulants). If not and the tests are for screening or pre-op purposes, insurers probably won't cover the tests.

You mentioned the following codes for the tests:

• 85025 -- Blood count; complete (CBC), automated (Hgb, Hct, RBC, WBC and platelet count) and automated differential WBC count
• 85610 -- Prothrombin time
• 85730 -- Thromboplastin time, partial (PTT); plasma or whole blood.

Payers generally consider testing prior to any medical intervention associated with a risk of bleeding and thrombosis (other than thrombolytic therapy) medically necessary only under certain circumstances. These can include signs or symptoms of a bleeding or thrombolytic abnormality; or personal history of bleeding, thrombosis, or a condition associated with coagulopathy. Hospital or clinic policies or protocols (in and of themselves) cannot justify coverage.

Resource: ICD-9 Guidelines also include some direction regarding diagnostic tests performed as routine pre-operative screenings. The guidelines state, "For encounters for routine laboratory/radiology testing in the absence of any signs, symptoms, or associated diagnoses, assign V72.5 and/or a code from subcategory V72.6. ... For patients receiving pre-operative evaluations only, sequence first a code from category V72.8 (Other specified examinations) to describe the pre-op consultations. Assign a code for the condition to describe the reason for the surgery as an additional diagnosis. Code also any findings related to the pre-op evaluation."