Oncology & Hematology Coding Alert

Here’s how to stay on top of this rapidly changing CPT^® subsection.

CPT^® 2023 contains a large number of changes to the proprietary laboratory analyses (PLA) codes. In all, you’ll see 84 new, revised, or deleted codes in the latest edition; of them, four of the deletions, two of the revisions, and 31 new analyses directly affect the oncology and hematology specialties. “There are, however, additional tests that may have an impact regarding the use and billing of tests with characteristics benefiting oncology and hematology providers,” says Kelly Loya, CPC, CHC, CRMA, CPhT, CHIAP, associate partner at Pinnacle Enterprise Risk Consulting Services, Charlotte, North Carolina.

Here’s a roundup of some of the PLA revisions that you should know about, along with information about when the changes will take, or have taken, effect. But before we get there, we’ve included some information about what PLAs are, why CPT^® has two subsections devoted to them, and why they take precedence over other CPT^® test codes.

Know What PLA Codes Describe

According to CPT^®, the PLA codes “describe proprietary clinical laboratory analyses that can be provided either by a single (“sole source”) laboratory or licensed or marketed to multiple providing laboratories (eg, cleared or approved by the FDA).” In other words, each PLA code is unique to a commercial test made by a specific manufacturer.

The PLA codes include “advanced diagnostic laboratory tests (ADLTs) and clinical diagnostic laboratory tests (CDLTs)” that are “covered under Medicare Part B” through the Protecting Access to Medicare Act (PAMA) of 2014, according to CPT^® Assistant Volume 28, Issue 8 (August 2018).

Know When to Use a PLA Code Over a Path/Lab Code

CPT^® guidelines tell you that “when a PLA code is available to report a given proprietary laboratory service, that PLA code takes precedence. The service should not be reported with any other CPT^® code(s) and other CPT^® code(s) should not be used to report services that may be reported with that specific PLA code.” So, “when a specific PLA code is not listed, the test must be reported using either a CPT^® Category I (or Category III, if available) laboratory code or an administrative MAAA code,” according to CPT^® Assistant.

Remember: CPT^® tells you the services described by PLA codes “encompass all analytical services required for the algorithmic analysis,” including cell lysis. However, “you can report additional procedures prior to cell lysis for molecular analyses separately,” notes Leah Fuller, CPC, COC, senior consultant, Pinnacle Enterprise Risk Consulting Services, in Charlotte, North Carolina. For example, for tests that require microdissection to obtain a cell sample for testing purposes, you may report the microdissection separately using either 88380 (Microdissection (ie, sample preparation of microscopically identified target); laser capture) or 88381 (… manual) as appropriate for the method of obtaining the specimen.

Know That CPT^® Lists PLA Codes in Appendix O, Too

You can also look up a specific PLA test in Appendix O of your CPT^® code book. There, you can find information about manufacturer.

Know These PLA Add Highlights for 2023

For hematology, the DNA test for myelogenous leukemia (0056U) has been deleted effective Oct. 1, 2022, while new red blood cell (RBC) adhesion (0303U and 0304U) and RBC functionality and deformity (0305U) tests, have been added to CPT^® 2023, though all were effective Jan. 1, 2022.

For oncology, CPT^® 2023 adds minimal residual disease (MRD) analyses 0306U and 0307U (both effective Apr. 1, 2022); pan tumor genome mapping tests 0297U, 0298U, and 0300U (all effective Jan. 1, 2022); cutaneous melanoma and cutaneous squamous cell carcinoma mRNA gene expression tests 0314U and 0315U (both effective Apr. 1, 2022); and ovarian spheroid cell culture chemotherapy response prediction tests 0324U and 0325U (both effective July 1, 2022), among the new oncology-specific PLA tests.

Of special interest, “0022U is used for gene sequencing for non-small cell lung cancer (NSCLC), 0229U identifies biomarkers of colorectal cancer, and 0326U is a test approved as a comprehensive liquid biopsy for all advanced solid tumors,” Loya notes.

For the full list of PLA test additions, deletions, and revisions to CPT^® 2023, along with their effective dates, go to www.ama-assn.org/system/files/CPT^®-pla-codes-long.pdf.