Oncology & Hematology Coding Alert

Modifier indicator change from '1' to '0' ties labs' hands.

Correct Coding Initiative (CCI) 16.1, Physician Version, appeared to open the door for reporting a medically necessary complete blood count (CBC) with subsequent transcutaneous hemoglobin later in the day -- as has and continues to be allowed for APC facility billing according to the current Hospital APC version of CCI. But CCI 16.2 slams that door shut.

Think Twice Before Coding 2 Hemoglobins

If you've got your own lab, it might get a request for two medically necessary hemoglobin tests by different methods in a single day for the same patient. You won't be able to bill for both, according to CCI 16.2.

CCI has 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]) since Jan. 1. CCI 16.0 listed a "0" modifier indicator, meaning that you couldn't override the edit pair under any circumstances.

But CCI 16.1 changed the modifier indicator to "1," giving labs hope that they could override the edit pair using modifier 59 (Distinct procedural service), when appropriate.

For instance: "The lab might perform a complete blood count (such as 85025) for an infant, and based on a low hemoglobin count, perform a transcutaneous hemoglobin (88738) later in the day," says William Dettwyler, MTAMT, president of Codus Medicus, a laboratory coding consulting firm in Salem, Ore. "With these edit pairs in place, the lab could not bill for both procedures."

Bad news: Not only does CCI 16.2 (effective July 1 for physicians) reinstate the "0" modifier indicator so that you cannot override the edit pairs, but the change is retroactive to Jan. 1. That means you might see payment adjustments for any claims filed during quarter two of 2010 with both a CBC and transcutaneous hemoglobin test.

Note that CCI doesn't bundle the hemoglobin chemistry codes such as 83020 (Hemoglobin fractionation and quantitation) with the 85025, so the lab could bill a "stick" hemoglobin, but not a transcutaneous hemoglobin, in addition to the CBC.