Oncology & Hematology Coding Alert

Noting the retroactive date could pay off.

If your center has a lab, it might get a request for two medically necessary hemoglobin tests by different methods in a single day, and as of last quarter, you couldn't bill for both, according to the Correct Coding Initiative (CCI) edits for physicians. but the October release brought different news.

Modifier Indicator Matters for Reimbursement

Effective Jan. 1, 2010, CCI bundled 88738 (Hemoglobin [Hgb], quantitative, transcutaneous) with 85025 (Blood count; complete [CBC], automated [Hgb, Hct, RBC, WBC, and platelet count] and automated differential WBC count) and 85027 (... complete [CBC], automated [Hgb, Hct, RBC, WBC, and platelet count]).

Whether you can unbundle these edit pairs for distinct specimens by using a modifier has been a changing proposition each quarter this year. Here's the CCI modifier indicator for these edit pairs over the course of 2010:

• CCI 16.0 -- modifier indicator "0" effective Jan. 1, 2010
• CCI 16.1 -- modifier indicator "1" retroactive to Jan. 1, 2010
• CCI 16.2 -- modifier indicator "0" retroactive to Jan. 1, 2010››
• CCI 16.3 -- modifier indicator "1" retroactive to Jan. 1, 2010.

A modifier indicator of "0" means that you can't override the edit pair under any circumstances, explains William Dettwyler, MTAMT, president of Codus Medicus, a laboratory coding consulting firm in Salem, Ore.

Now that CCI 16.3 changes the modifier indicator back to "1," labs should know that they can override the edit pair using modifier 59 (Distinct procedural service), when appropriate. For instance: The lab might perform a complete blood count, coded as 85025, for an infant. Then later in the day, the lab may perform a transcutaneous hemoglobin (88738) because the patient showed a low hemoglobin count, Dettwyler says. "With these edit pairs in place, the lab could bill for both procedures, but would need to override the edit pair by appending modifier 59 to 88738."

Good news: Now that CCI 16.3 reinstates the "1" modifier indicator retroactive to Jan. 1, you should be able to seek payment adjustments for any claims filed during the first and third quarters of 2010 for distinct CBC and transcutaneous hemoglobin tests on the same day.