Pathology/Lab Coding Alert

Molecular pathology includes every step.

Each January, you can expect new Correct Coding Initiative (CCI) edits to follow new CPT® codes as surely as weight loss plans follow the holidays.

“As is customary for the first update of a given year, there are a lot of new edit pairs: 61,120 to be exact,” says Frank Cohen, MPA, MBB, principal and senior analyst for The Frank Cohen Group in Clearwater, Fla. “Factor in the number of terminations (13,107) and we see a net gain this coming quarter of 48,013 new edit pairs.”

Read on, because you can’t afford to miss nearly 500 new CCI bundles that will impact your lab coding and billing.

Molecular Pathology Codes Stand Alone

When your lab performs a specific molecular pathology test from Tier 1 (81161-81355 and human leukocyte antigen [HLA] 81370-81383) or Tier 2 (81400-81408), the procedure involves analyzing nucleotide variants.

CCI 20.0 ensures that you don’t double bill for the service by bundling the following two codes with all molecular pathology procedures:

• 81228 — Cytogenomic constitutional (genome-wide) microarray analysis; interrogation of genomic regions for copy number variants (e.g., bacterial artificial chromosome [BAC] or oligo-based comparative genomic hybridization [CGH] microarray analysis
• 81229 — … interrogation of genomic regions for copy number and single nucleotide polymorphism (SNP) variants for chromosomal abnormalities.

CCI 20.0 also bundles the following two multi-analyte assays with algorithmic analyses (MAAA) codes with Tier 1 and Tier 2 molecular pathology codes 81161-81355 and 81400-81408:

• 81504 — Oncology (tissue of origin), microarray gene expression profiling of > 2000 genes, utilizing formalin-fixed paraffin-embedded tissue, algorithm reported as tissue similarity scores
• 81507 — Fetal aneuploidy (trisomy 21, 18, and 13) DNA sequence analysis of selected regions using maternal plasma, algorithm reported as a risk score for each trisomy.

You’ll need to heed additional edit pairs that bundle 81504 and 81507 with the following codes:

• 84311 — Spectrophotometry, analyte not elsewhere specified
• 88291 — Cytogenetics and molecular cytogenetics, interpretation and report
• G0452 — Molecular pathology procedure; physician interpretation and report
• 88271-88275 — Molecular cytogenetics …
• 88365-88368 — …In situ hybridization [ISH]…

Bottom line: Choose the single, most specific code that describes the molecular procedure your lab performs. Don’t additionally report other codes that describe one of the procedure methods or represent other types of tests, such as cytogenetics or ISH.

Need to know: All of these edit pairs have a modifier indicator of “1,” not “0.” The “0” indicator means that you cannot unbundle the two codes under any circumstances, says Chandra L. Hines, practice supervisor of Wake Specialty Physicians in Raleigh, NC. An indicator of “1,” however, means that you may use a modifier to override the edit if the clinical circumstances warrant separate payment, she adds.

So if your lab performs two distinct tests represented by two of these bundled codes, you can override the edit pair by appending modifier 59 (Distinct procedural service) to the column 2 code.

Pick Most Specific Organism Code

You’ll find new CCI 20.0 edit pairs for some new and revised CPT® 2014 infectious agent detection codes.

For instance, CCI 20.0 bundles 84112 (Evaluation of cervicovaginal fluid for specific amniotic fluid protein[s] [e.g., placental alpha microglobulin-1 (PAMG-1), placental protein 12 (PP12), alpha-fetoprotein], qualitative, each specimen) with serum and amniotic fluid AFP codes 82105-82017 (Alpha-fetoprotein [AFP] …). That means you should select the most specific code and not report two of these codes together for the same test.

Similarly, if you report new CPT® 2014 code 87661 (Infectious agent detection by nucleic acid (DNA or RNA); Trichomonas vaginalis, amplified probe technique) for an amplified probe molecular method, CCI 20.0 restricts you from additionally reporting any of the following codes for the same test:

• 87660 — … direct probe technique
• 87808 — Infectious agent antigen detection by immunoassay with direct optical observation; Trichomonas vaginalis.

Again, you need to select the single code that most accurately describes the lab method used to test for the organism.

Check out these edit pairs: CCI 20.0 also bundles new code 87661 with the following codes:

• 87177 — Ova and parasites, direct smears, concentration and identification
• 87800 — Infectious agent detection by nucleic acid (DNA or RNA), multiple organisms; direct probe(s) technique
• 80500-80502 — Clinical pathology consultation …
• 81400-81408 — Tier 2 molecular pathology.

Unbundle: Based on the modifier indicator of “1,” you may override any of these edit pairs if you have documentation for medical necessity of two distinct tests.