Pathology/Lab Coding Alert

Watch modifier indicator for override options.

Your lab faces nearly 75 new edit pairs under the latest Correct Coding Initiative (CCI) update, effective April 1, 2013, even though the number of added pairs is minor, overall.

With only 744 new edit pairs in the entire release, CCI 19.1 “is probably the smallest impact I have seen since the beginning of the program,” says Frank D. Cohen, MPA, MBB,senior analyst with The Frank Cohen Group, LLC, in his analysis of the changes.

That doesn’t mean you can afford to ignore the update. Read on to see what you need to know to ensure that you continue to receive proper payment for your lab services.

Get Specific With Molecular Pathology

If you’re performing molecular testing for a specific genomic region, you need to choose just one code from the CPT^® family that describes the tests. That’s the principle inherent in 32 new CCI edit pairs that bundle numerous Tier 1 molecular pathology codes in the range 81200-81355.

For instance: If your lab tests for cystic fibrosis transmembrane conductance regulator (CFTR), you should use the single most specific/comprehensive code from the following list that describes certain variants tested:

·         81220 — CFTR (e.g., cystic fibrosis) gene analysis; common variants (e.g., ACMG/ACOG guidelines)

·         81221 — …known familial variants

·         81222 — …duplication/deletion variants

·         81223 — …full gene sequence

CCI 19.1 adds two edit pairs for these codes, listing 81222 as a column 2 code to 81220 and 81223, with a modifier indicator of “1.”

Prior to April 1, CCI already provided edits that disallow billing many of these codes together under any circumstances (modifier indicator “0”) with the following column 1 column 2 code pairs:

·         81221, 81222

·         81220, 81221

·         81223, 81221

·         81223, 81220

Coder tip: “Under certain circumstances, you may override CCI edit pairs with a modifier indicator of 1 by using an appropriate modifier such as 59 (Distinct procedural service). But you can never override a CCI edit pair with a modifier indicator of 0,” instructs William Dettwyler, MTAMT,president of Codus Medicus, a laboratory coding consulting firm in Salem, Ore.

Logic for edits: CCI 19.1 lists all the new Tier 1 molecular pathology edit pairs with the policy statement “mutually exclusive procedures” or “more extensive procedure.” In other words, codes for the “full gene sequence” typically include (are more extensive than) tests for specific variants, and distinct tests for different variants of the same gene are typically mutually exclusive (you would test one or the other, not both).

Avoid Multiple Molecular HLA Typing Codes

CCI 19.1 adds more than 40 new edit pairs for molecular human leukocyte antigen (HLA) typing codes in the range 81370-81383.

As with the Tier 1 edits, many of these are based on the CCI “more extensive procedure” policy.

For instance: Under that policy, you’ll find a new edit pair for column 1 code 81379 (HLA Class I typing, high resolution [i.e., alleles or allele groups]; complete [i.e., HLA-A, -B, and -C]) with column 2 code 81375 (HLA Class II typing, low resolution [e.g., antigen equivalents]; HLA-DRB1/3/4/5 and -DQB1).

Watch modifier: Just one new HLA edit pair shows modifier indicator “0” — 81372 (HLA Class I typing, low resolution [e.g., antigen equivalents]; complete [i.e., HLA-A, -B, and -C]) with 81375.

Here’s why: If your lab performs a low resolution HLA class I and II typing, you should use 81370 (HLA Class I and II typing, low resolution [e.g., antigen equivalents]; HLA-A, -B, -C, -DRB1/3/4/5, and -DQB1) instead of reporting together 81372 and 81375. CPT instruction directs coders to 81370, and now CCI edits enforce this correct coding.