Pathology/Lab Coding Alert

You can't afford to get the date of service (DOS) wrong on claims that undergo CMS edits -- mistakes could mean you'll face fraud charges. That's because Correct Coding Initiative (CCI) edits and Medically Unlikely Edits (MUEs) control payment for procedures on the same DOS.

But for pathologists, choosing the date has never been clear-cut. "For instance, should you use the date the surgeon took the biopsy, the date the lab processed special-stain slides from the biopsy specimen, or the date the pathologist interpreted those slides?" asks Pamela Biffle, CPC, CPC-I, CCS-P, ACS-DE, principal for PB Healthcare Consulting and Education in Fort Worth, Tex.

Do this: If you're billing for clinical laboratory tests or the technical component (TC) of physician pathology services, you'll need to adhere to the following five rules.

See "Easily Identify When Lab DOS Rules Apply to You" on page 69 to make sure you know when you need to follow these DOS guidelines.

CMS's general rule is that the DOS is the date of specimen collection.

Example 1: A physician office draws blood on Sept. 1 and sends it to a laboratory for a lipid profile. The lab runs the profile on Sept. 3 and bills procedure code 80061 (Lipid panel). The lab should report Sept. 1 as the DOS.

Example 2: A surgeon performs a breast resection on June 4. Your pathology lab receives a tissue sample for IHC testing on June 6. Your lab performs a quantitative ER/PR, Her-2/neu breast tumor analysis using an automated platform on June 7.

You should bill for 88361 x 3 (Morphometric analysis, tumor immunohistochemistry [e.g., Her-2/neu, estrogen receptor/progesterone receptor, quantitative or semiquantitative, each antibody; using computer-assisted technology). "Because the code definition for 88361 designates 'per antibody,' each of the tests for ER, PR, and Her-2/neu warrants a separate code," says Melanie Witt, RN, CPC, COBGC, MA, a coding expert based in Guadalupita, N.M.

The Medicare Physician Fee Schedule lists 88361 with modifier TC, so you'll need to list the DOS as June 4 if you're billing for the technical component.

Sometimes labs collect specimens over a period spanning multiple calendar days. That's when you should follow the "corollary rule": the DOS is the date collection ended.

For example: Your lab processes a 24-hour urine creatinine test, beginning collection at 8 a.m. on Jan. 6 and ending at 8 a.m. on Jan. 7. Report 82570 (Creatinine; other source) and use the second day of urine collection -- Jan. 7 -- as the DOS.

The DOS rules are different for an "archived" specimen, which CMS defines as one that has been in storage for more than 30 days. For archived specimens, the DOS is the date that you obtain the specimen from storage.

For instance: Your lab receives a tissue specimen along with a request for pathology consultation dated Jan. 27, 2009. The tissue is from a Feb. 22, 2006, mastectomy case. The lab prepares additional slides and the pathologist interprets them on Jan. 29, 2009.You should report the service as 88323 (Consultation and report on referred material requiring preparation of slides). If you're billing globally or billing only the TC, you must list the DOS as Jan. 27, 2009.

Rules 1 and 3 mean that the DOS is always the specimen-collection date unless it's archived -- right?

Wrong. Sometimes you'll report DOS as the procedure date for when a specimen has been "stored" at least 14 days but not "archived."

Exception: The lab DOS is the date that you perform the service, not the specimen collection date, if you meet these criteria:

• Physician ordered the test/service at least 14 days following patient hospital discharge

• Physician collected specimen while patient underwent hospital surgical procedure

• Collecting sample other than during hospital procedure would be medically inappropriate

• Results of test/service do not guide treatment during hospital stay

• Test/service was reasonable and medically necessary.

Example: Following a lymph node biopsy and exam on March 1, the oncologist sends your lab the paraffinfixed specimen on March 17 for T-Cell Receptor (TCR) gene rearrangement assay to aid in diagnosing T-cell malignancy, which you perform on that day.

Your lab should bill the assay with the appropriate molecular diagnostics codes (83890-83912, Molecular diagnostics ...) using March 17 as the DOS.

Chemotherapy sensitivity testing uses a fresh tissue sample to test tumor-cell sensitivity to different chemotherapeutic agents. The DOS for these services is the specimen collection date unless you meet these criteria, in which case you'll report the test date:

• Physician makes decision regarding chemotherapeutic agent test at least 14 days following patient hospital discharge

• You meet all other criteria for stored but not archived rule.

Resource: You can read the laboratory DOS policy in the Medicare Claims Processing Manual (Internet Only Manual 100-04), Chapter 16, Section 40.8, available at www.cms.hhs.gov/manuals/downloads/clm104c16.pdf.