Pathology/Lab Coding Alert

Keep claims-filing rules straight for bundled codes.

CPT^® 2018 brought you lots of new lab codes, so you shouldn't be surprised that lots of new Correct Coding Initiative (CCI) procedure-to-procedure (PTP) edits followed for the first quarter of 2018. Read on to make sure you know about edit pairs and edit rules that could impact your lab's pay.

Remember: CMS reviews and revises PTP edits on a quarterly basis, and this data is usually available several weeks before the start of a new quarter, according to Ruby Woodward, BSN, CPC, CPMA, CPB, COSC, CSFAC, CPC-I, coding and compliance manager at Suburban Imaging/Suburban Radiologic Consultants in Minneapolis, Minnesota. "I strongly recommend not relying on memory and always checking the edits when submitting claims for multiple services on the same date of service," she says.

Keep PLA Distinct

For the 17 new Proprietary Laboratory Analyses (PLA) codes that made it to the print version of CPT^® 2018, CCI establishes a host of edit pairs. CCI 24.0 does not deal with other PLA codes that the AMA has since approved.

Each PLA code in the range 0001U-0017U represents a specific clinical laboratory test by a unique lab or manufacturer. When using one of those unique "brand name" tests, you must use the appropriate PLA code instead of a more "generic" CPT® code that might adequately describe the analyte or procedure.

Watch for: The new CCI edits essentially bundle each PLA code with existing CPT® codes that describe lab methods or analytes that are similar to the PLA code. In other words, you should report just the single, most specific code for the test.

For instance: With new code 0001U (Red blood cell antigen typing, DNA, human erythrocyte antigen gene analysis of 35 antigens from 11 blood groups, utilizing whole blood, common RBC alleles reported) CCI 24.0 bundles the following codes that describe similar lab methods and/or analytes (abbreviated descriptors):

• 81340 for T-cell antigen receptor beta and 81342 for T-cell antigen receptor gamma
• New codes 81361-81364 for hemoglobin subunit beta (HBB)
• 81370-81383 for human leukocyte antigen (HLA) typing, molecular pathology
• 81400-81408 for Tier 2 molecular pathology codes
• 84311 Spectrophotometry for unlisted analyte
• 88271-88275 for molecular cytogenetics
• 88364-88377 for tissue in situ hybridization (ISH).

Beware Common Bundle Pitfalls

Many of the new CPT^® 2018 codes for lab and pathology describe molecular tests, either molecular pathology Tier 1 or Tier 2, or genomic sequencing procedures (GSPs) or multianalyte assays with algorithmic analyses (MAAAs), and some of the PLA tests.

Following a past pattern, CCI 24.0 bundles each new CPT^® 2018 code in these categories with 80500-80502 (Clinical pathology consultation ...). That's because these molecular tests are primarily clinical lab tests that do not require a physician interpretation. But if a clinician specifically requests a pathologist's interpretation of the test, you should report G0452 (Molecular pathology procedure; physician interpretation and report) for the service, not 80500 or 80502.

Caution: You're not out of the woods with reporting G0452. CCI 24.0 also presents systematic bundles between new MAAA codes and G0452. Because the MAAA tests include an algorithm and reports a "risk score," CMS bundles the interpretation as a column 2 code for MAAA tests.

Also notice that CCI 24.0 adds edit pairs for many new molecular, GSP and MAAA codes with 88291 (Cytogenetics and molecular cytogenetics, interpretation and report). You should reserve 88291 to describe interpretation of cytogenetic studies described by codes in the range 88230-88289.

To better understand the ins and outs of reporting pathologist services with molecular procedures, refer to "Beware Pathology Consultation with Molecular Test Codes" in Pathology/Lab Coding Alert Vol. 18, No. 7.

Avoid Drug Testing Edits

Several of the new PLA codes describe drug-monitoring procedures, as follows:

• 0006U (Prescription drug monitoring, 120 or more drugs and substances, definitive tandem mass spectrometry with chromatography, urine, qualitative report of presence (including quantitative levels, when detected) or absence of each drug or substance with description and severity of potential interactions, with identified substances, per date of service)
• 0007U (Drug test(s), presumptive, with definitive confirmation of positive results, any number of drug classes, urine, includes specimen verification including DNA authentication in comparison to buccal DNA, per date of service)
• 0011U (Prescription drug monitoring, evaluation of drugs present by LC-MS/MS, using oral fluid, reported as a comparison to an estimated steady-state range, per date of service including all drug compounds and metabolites)

CCI 24.1 ensures that you don't double-dip with other drug test codes by bundling these PLA drug codes with the following tests (abbreviated descriptors):

• 80305-80307: presumptive drug testing
• 80320-80377: definitive drug testing
• 82542, 83789, and 84311: unlisted-analyte method codes (chromatography, mass spectrometry, spectrometry)
• 82570, 83986, 84156: sample validation tests such as urine creatinine, pH, and protein
• G0480-G0483 and G0659: HCPCS drug test codes.

Watch for '0' Modifier Indicator

CMS publishes CCI's PTP edits with a "modifier indicator" column showing a "1" or "0."

The modifier indicator of "1" means that you can override these edits, if appropriate, by using a modifier such as modifier 59 (Distinct procedural service), according to Mary I. Falbo, MBA, CPC, president and CEO of Millennium Healthcare Consulting Inc. in Lansdale, Pennsylvania.

On the other hand, you cannot override edits with a "0" modifier indicator under any circumstances.

For instance: All of the new PLA drug tests bundled with HCPCS drug test codes discussed in the previous section show a "0" modifier indicator.

Same gene: You'll find another pattern in CCI edits to list modifier indicator "0" with full gene sequence analysis for a family of codes that describe interrogating different variants of the same gene.

Keeping to that standard, version 24.0 adds new edit pairs that you can never override for each of the following codes paired with 81364:

• 81361 (HBB (hemoglobin, subunit beta) (eg, sickle cell anemia, beta thalassemia, hemoglobinopathy); common variant(s) (eg, HbS, HbC, HbE))
• 81362 (...known familial variant(s))
• 81363 (...duplication/deletion variant(s))
• 81364 (...full gene sequence).

Editor's note: These edits are just a sample of what you should be aware of surrounding the 2018 lab updates - not an exhaustive list. Visit www.cms.gov/Medicare/Coding/NationalCorrectCodInitEd/Version_Update_Changes.html for the complete list of CCI 24.0 edits.