Oncology & Hematology Coding Alert

If confusion over laboratory codes is slowing your reimbursement stream, it's time to get familiar with the new rules issued by CMS for laboratory services.

Published as the "Final Rule for Coverage and Administrative Policies for Clinical Diagnostic Laboratory Services" in the Nov. 23, 2001, Federal Register (FR, pages 58832-3), the directive will help reimbursement for prothrombin tests to flow more freely.

Having national coverage standards for these tests will be especially beneficial for coders in oncology labs that operate under the jurisdiction of more than one carrier or are subject to conflicting LMRPs, says Kenneth Wolfgang, MT (ASCP), PCP, CPC-H, member of the national advisory board of the AAPC and director of coding and analysis for National Health Systems Inc., Camp Hill, Pa.

Oncology practices that own their own labs stand to benefit specifically from the part of the rule that makes coding for prothrombin time (PT) tests more efficient by blocking easy denials based on test frequency, and by encouraging physicians to document essential diagnosis information.

Cancer patients susceptible to blood clots require anticoagulation medication, whose effectiveness is periodically measured by prothrombin time tests. The coagulation tests, or "pro time," as they are commonly called, span 85610 (Prothrombin time) and 85611 (Prothrombin time; substitution, plasma fractions, each), and assess coagulation and the extrinsic or tissue factor dependent pathway.

Other tests that measure coagulation include partial thromboplastin time (PTT), 85730; thrombin time (TT), 85670; and quantitative fibrin degradation determination, 85370. When coding, it is important to note that these slightly different tests require different codes. The PTT test assesses the intrinsic limb of the coagulation system, while the TT and quantitative fibrinogen determination measure fibrinogen concentration.

Inserting cancer diagnosis codes into your blood-clotting treatment claims will lead to denials. Ordered PT tests need non-cancer-related diagnosis codes for justifying reimbursement, emphasizes Elaine Towle, CMPE, practice administrator for New Hampshire Oncology and Hematology in Hooksett. If a patient with breast cancer receives chemotherapy and takes an antico-agulation medication like Coumadin, the breast cancer, in this case, is not a "billable diagnosis," she says.

The justification for the test is a residual disease potentially caused by the cancer, but not the cancer itself, says Laurie Castillo, MA, CPC, president of Physician Coding and Compliance Consulting and the AAPC's Virginia chapter, both in Manasses, Va.

Documenting the disease that directly contributes to the blood clots will lead to reimbursement. Often, medical conditions like arterial fibrillation and other cardiac conditions qualify for medical necessity, Towle says. "Frequently we see patients with some sort of thrombosis or clot and use a diagnosis in the 453.0-453.9 range."

Other relevant codes include embolism codes- 444.9 (artery), 434.1x (brain), 444.22 (extremities) and 453.9 (vein) - or thrombosis codes.

When searching for a diagnosis code, coders can check to see what the PT tests measured. Prothrombin tests don't only measure the effect of warfarin. They also evaluate liver failures, vitamin K deficiency, and dysfi-brinogenemia, to name a few. Knowing what the PT test measured helps determine the appropriate diagnosis code.

Oncology practices may be tempted to try to tap into additional PT testing reimbursement for E/M services and review of codes. The justification is that even if an outside lab processes the test, the oncologist must evaluate and update the test results as they are received. "Coumadin patients are different; they require more evaluation, notification and reminders," says Karen Cowan, office manager of Pine Tree Internal Medicine, Farmington, Maine.

In spite of all of the transcribing and evaluating, Cowan's practice does not charge an extra evaluation and management service for this work. "We don't bill for a review of results," she says. "We believe that the patient has a right to know the results of their lab test."

Kathy Pride, CPC, coding supervisor for Martin Memorial Medical Group, Stuart, Fla., agrees that it is not appropriate to bill for even the lowest level of office E/M service, 99211. "You can't bill for a review of test results that were faxed. There has to be face-to-face contact in order to report an E/M service," she says. "This is a potentially fraudulent use of code 99211."

However, review of test results during the patient's next office visit may alter the level of E/M service to report. "The review of test results is part of the amount and/or complexity of data to be reviewed, which is an element in determining the complexity of medical decision-making that occurred," Pride says.