Pathology/Lab Coding Alert

Know when you can override edits.

If your lab performs bladder tumor tests or molecular pathology procedures, you need to know about additions to Medicare’s Correct Coding Initiative (CCI) version 19.2, which takes effect July 1, 2013.

Good news: Lab and pathology practices have few new edit pairs to worry about this time around, even though in version 19.2, "the number [of changes] approaches 300,000, so this one is a whopper," according to Frank Cohen, MPA, MBB, principal and senior analyst for The Frank Cohen Group in Clearwater, Fla.

Shun 80500 With G0452 — Sometimes

If you’re reporting molecular pathology tests using Tier 1 and Tier 2 CPT codes (81200-81479), you might sometimes report G0452 (Molecular pathology procedure; physician interpretation and report) to capture your pathologist’s interpretation of molecular test results.

As you hone your skills for using G0452 (see "Capture Unit of Service Bonus with G0452 Interpretation" in this issue), you need to remember one more restriction handed down courtesy of CCI 19.2. That is, don’t report G0452 with 80500 (Clinical pathology consultation; limited, without review of patient’s history and medical records) or 80502 (…comprehensive, for a complex diagnostic problem, with review of patient’s history and medical records).

CCI 19.2 adds new edit pairs for these codes, stating that G0452 is a "mutually exclusive procedure" with either 80500 or 80502. You should select G0452 as the most specific code available when your pathologist performs a specific type of clinical pathology interpretation involving molecular pathology tests. Don’t double-report the single service by also reporting 80500 or 80502.

Exception: CCI lists these edit pairs with a modifier indicator of "1." "That means you can override the edit pair using an appropriate modifier, such as 59 (Distinct procedural service) under certain circumstances," explains William Dettwyler, MTAMT, president of Codus Medicus, a laboratory coding consulting firm in Salem, Ore. For instance, if your pathologist provides an interpretation and report for a molecular pathology test (G0452) and also provides a separate consultation for a different clinical lab test, you can additionally report 80500 or 80502 with modifier 59.

Select One Bladder Tumor Code

CCI 19.2 also adds an edit pair for 86294 (Immunoassay for tumor antigen, qualitative or semiquantitative [e.g., bladder tumor antigen]) and 86386 (Nuclear Matrix Protein 22 [NMP22], qualitative).

Unlike the other new lab edit pairs in version 19.2, this pair has a modifier indicator of "0," meaning that you can’t override the edit pair under any circumstances.

Distinguish bladder tumor tests: Some bladder tumor tests, such as BladderChek®, involve a qualitative urine test specifically for Nuclear Matrix Protein number 22 (NMP22). NMP22 is an abnormal protein whose presence in the urine might indicate a bladder tumor. Physicians may use the test diagnostically, or to monitor bladder cancer progress during treatment. You should always select the most specific code for a test, and in this case, that’s 86386.

The other code in this edit pair — 86294 — is a more general code that describes an immunoassay for tumor antigens, and may be qualitative or semi-quantitative. You would use 86294 for other immunoassay tumor antigen tests that don’t have a more specific code.

For instance, another bladder cancer test, BTA stat®, checks for a bladder tumor associated antigen that is part of the complement factor H related protein (CFHrp). This test does not check for NMP22. The correct code for this test is 86294.

Because physicians may order one or the other, but not both tests, to identify bladder tumors, CCI considers the tests "mutually exclusive."