Pathology/Lab Coding Alert

Avoid unlisted-procedure codes for new tests

Don't ignore those strange alphanumeric codes listed at the back of your CPT book. You should be using those Category III codes because they will pay off in the future.
 
The problem: Your natural instinct is to leave these codes alone because Medicare won't pay for many Category IIIs but will pay for unlisted-procedure codes. But if you choose to stick only with the tried-and-true Category I codes, you're cheating yourself out of future payment.
 
What they are: The AMA developed CPT III codes for new and emerging technologies, says Franz Ritucci, MD, DABAM, FAEP, director of the American Academy of Ambulatory Care in Orlando, Fla. And because the AMA uses the codes to gather usage data, reporting Category IIIs could contribute to creating future Category I codes that will pay.
 
Unlike lab tests for Category I codes, Category III lab tests may not have Food and Drug Administration approval. And the AMA disclaims that including a test as a Category III code implies "clinical efficacy or safety." But if your lab uses the test, you should use the code.
 
Important: In fact, AMA coding instruction requires that "if a Category III code is available, this code must be reported instead of a Category I unlisted code."
 
Example: A lab performs a phospholipid cofactor antibody test. The coder should bill Category III code 0030T (Antiprothrombin [phospholipid cofactor] antibody, each Ig class) to Medicare. For private payers, however, you may need to bill 86849 (Unlisted immunology procedure). Contact your payers for billing and payment instructions.

Learn How to Find Category III Codes

If your lab is doing a new test and you don't know the CPT code, how can you find out if a Category III code describes the test?
 
Predicament: Unlike Category I codes, Category III codes aren't subdivided by type of service. They're listed in increasing numerical order based on the year the code was added. You might have a surgical code and a lab test next to each other, so how can you find the codes you need?
 
Solution: Use our handy tool, "Put Category III Lab Codes at Your Fingertips," on page 53. We've done the work for you and listed all Category III codes that labs might use, along with a description of common clinical applications and methods to help you identify the test.
 
You'll also find lots of references in CPT text notes that will help you know when a similar test has a Category III code assigned.
 
For instance: If your lab performs a serum test for intermediate-density lipoproteins, you might look for the code near the high-density (HDL) and low-density (LDL) cholesterol tests. Reading the notes following 83721 (Lipoprotein, direct measurement; LDL cholesterol) you'll notice a reference to the test you want: "To report direct measurement, intermediate-density lipoproteins (remnant lipoproteins), use Category III code 0026T."
 
Do this: When the new codes come out each year, don't just look at the 80000 section. Take the time to look for new Category III codes in the back of the book and see if any describe procedures your lab already performs or might perform. This year, CPT 2006 added three new Category III codes:
 

 0103T -- Holotranscobalamin, quantitative 
 

 0111T -- Long-chain (C20-22) omega-3 fatty acids in red blood cell (RBC) membranes
 

 0140T -- Exhaled breath condensate pH.

Where Did They Go?

Category III codes don't hang around forever. The AMA archives each code after five years from its inception "unless it is demonstrated that a temporary code is still needed," according to the introduction to  the codes.
 
Payoff: But when coders begin reporting Category III codes, they might become Category I codes. Because the purpose of the codes is to allow data collection for emerging technologies and the requirement for Category I codes is that "the service/procedure be performed by many healthcare professionals … in multiple locations," you can see that reporting the Category III code actually helps it become a Category I code. And once a code is Category I, insurers start to pay.
 
Proof: Check out the Category III lab codes that converted to Category I in 2006:
 

 86480 (Tuberculosis test, cell mediated immunity measurement of gamma interferon antigen response) -- converted from 0010T
 

 87900 (Infectious agent drug susceptibility phenotype prediction using regularly updated genotypic bioinformatics) -- converted from 0023T.

Downside: Unfortunately, there is no guarantee of payment with Category III codes. The AMA says that payer policy dictates payment for these codes -- they are not on an annual fee schedule.
 
If your payer won't reimburse, determine an appropriate charge by assigning a fee that corresponds to the complexity of the procedure, says Rebecca Massey, CPC, CHC, senior consultant for Gates, Moore and Co. in Atlanta.
 
Good idea: If you report a Category III code to Medicare or other payers, "drop the claim to paper, and send a copy of the documentation to the payer for reimbursement," Massey says.