Pathology/Lab Coding Alert

Insurers base your payment on whether your claims show medical necessity -- and you can't demonstrate that without accurate diagnosis codes. Refresh your ICD-9 coding skills with four tips that make diagnosis coding a breeze.

Although lab payment -- like any other provider payment -- depends on an ICD-9 code that shows medical necessity, labs don't get to pick that code. The ordering physician must assign the ICD-9 code, or at least provide a narrative diagnosis, when ordering a lab test.

"Labs have always been caught in the middle because they have to report an ICD-9 code with a claim, yet they can't assign the diagnosis," says Stan Werner, MT (ASCP), administrative director of Peterson Laboratory Services PA in Manhattan, Kan.

Even if the lab test results indicate a particular condition, the lab can't assign an ICD-9 code based on test findings. Choosing a final diagnosis is up to the ordering physician based on clinical data and lab test results. The lab should stick to reporting the reason for the test when billing for the service.

Example: The physician suspects anemia in a 24-year-old patient who is experiencing heavy periods and orders a complete blood count (85025-85027, Blood count; complete [CBC] ...). The lab test results show a low hematocrit.

Solution: Despite lab test findings that point to anemia (such as 280.0, Iron deficiency anemia secondary to blood loss [chronic]), the lab should bill for the CBC using the ICD-9 code that describes the reason the physician ordered the test -- 626.2 (Excessive or frequent menstruation).

Best practice: Although labs can't assign the ordering diagnosis, they can provide physician education and design requisition forms to help ensure that a lab test has a payable diagnosis. Failing that, the lab can get a signed Advance Beneficiary Notice (ABN) so it can bill the patient for a non-covered test.

Pathologists follow a different set of diagnosis coding rules than clinical labs. Because the pathologist is a physician who often determines the final diagnosis for diseases such as cancer, the pathologist should report the most specific diagnosis available at billing time.

Example: A dermatologist submits a skin biopsy from a patient's arm to the pathologist for evaluation. The pathologist determines that the specimen is a malignant melanoma.

Solution: The pathologist should bill for the service (88305, Level IV " Surgical pathology, gross and microscopic examination; skin, other than cyst/tag/debridement/ plastic repair) using the final ICD-9 code 172.6 (Malignant melanoma of skin, upper limb, including shoulder).

Sometimes the pathologist will find that an anatomic pathology specimen doesn't demonstrate any abnormality.

In that case, you should bill the pathology service using the ordering ICD-9 code. In other words, you'll report why the physician sent the specimen, not what was wrong with it.

If you omit a required fifth digit when submitting ICD-9 codes, such as those for myeloid leukemia (205.00-205.92), you can anticipate claim denials, delays, and potential payer rejections. Fifth digits add additional information to the code, such as whether the leukemia is in remission or relapse.

The fifth digit allows the physician to provide greater detail, and when required, you must use the fifth digit to facilitate reimbursement, says Susan Vogelberger, CPC, CPC-H, CPC-I, CMBS, CCP-P, president of Healthcare Consulting and Coding Education LLC in Boardman, Ohio. Best practice: If you've dealt with denials due to missing fifth digits, you should print the applicable ICD-9 codes, including the fifth digits, right on your superbill. If you don't have enough room to list every fifth digit, you should place a line or symbol after codes that require a fifth digit to indicate the need for that information.

Example: Suppose you want to offer the physician the option of circling uncomplicated diabetes as the ordering diagnosis, but you want to indicate that he must report a fifth digit.

Solution: You can denote 250.0x (Diabetes mellitus without mention of complication ...). The x and the blank line prompt the physician to supply the fifth digit specifying type I or type II, and controlled or uncontrolled.

If you think that you should never report V codes (found near the back of the ICD-9 manual) as primary diagnosis codes, think again.

Practices can use V codes for primary diagnoses under certain circumstances. In fact, you must report some screening tests that Medicare covers with a specific V code.

Example: A physician orders a screening Pap test or screening PSA. Report the test with the appropriate V code, such as V76.2 (Special screening for malignant neoplasms; cervix; routine cervical Papanicolaou  smear) or V76.44 (... other sites; prostate).