Pathology/Lab Coding Alert

The Correct Coding Initiative (CCI) 8.1 took effect April 1, 2002, and will remain in effect until June 30, 2002. Pathology coders will need to be aware of a host of edit pairs that require a modifier if the services are performed and reported for the same patient on the same day.

"With nearly 600 new edit pairs in CCI version 8.1 , being familiar with the bulk of the changes presented here should help coders properly report bundled or mutually exclusive procedures if they are legitimately performed for the same patient on the same day," says Laurie Castillo, MA, CPC, CPC-H, CCS-P, member of the national advisory board of the American Academy of Professional Coders (AAPC) and president of Physician Coding and Compliance Consulting in Virginia. About 75 pathology code pairs are also deleted.

"Although many of the new edit pairs represent services that would not likely be performed concurrently, coders must be aware of the changes in order to override the edit on the occasion that these services legitimately occur together," says William Dettwyler, MT-AMT, coding analyst for Health Systems Concepts, a laboratory coding and compliance consulting firm in Longwood, Fla.

FNA Bundled with Biopsies

Most of the deletions and over 150 of the code pair additions involve fine needle aspiration (FNA) codes. Although the two FNA codes, 88170 and 88171, were replaced in CPT 2002 with new codes 10021 (Fine needle aspiration; without imaging guidance) and 10022 ( with imaging guidance), many edit pairs with the old codes remained in the CCI edits until this update. "Approximately 50 edit pairs containing the old FNA codes were deleted in CCI 8.1," Dettwyler says.

All of the deleted edit pairs involving 88170 and 88171, such as the pairing of each of these old FNA codes with breast biopsy codes (19100-19103), were replaced with new edit pairs using the new FNA codes (10021-10022). "Additionally, codes 10021 and 10022 were each paired with about 75 codes representing biopsy services that were not previously bundled with FNAs, for a total of about 150 new code pairs," Dettwyler says.

These biopsy codes are found in the various surgery sections of the CPT manual, ranging from 10000-60000-level codes. The code pairs are too numerous to list here, but they essentially encompass biopsy and some excision codes for any anatomic site, whether or not the procedure includes "needle" terminology. For example, the pairings include some needle biopsy codes such as 38505 (Biopsy or excision of lymph node[s]; by needle, superficial [e.g., cervical, inguinal, axillary]) as well as some excision codes such as 21555 (Excision tumor, soft tissue of neck or thorax; subcutaneous).

The FNA/biopsy code pairs are bundled under the CMS policy of "sequential procedures." The policy states, "On occasions where it is necessary that the same provider attempts several procedures in direct succession at a patient encounter to accomplish the same end, only the procedure that successfully accomplishes the expected result is reported." Under this policy, the listing of the FNA code in the component column, paired with a multitude of biopsy codes in the comprehensive column, indicates that an FNA procedure is not separately billable when followed by a biopsy of the same anatomic site.

"If, however, a pathologist performs an FNA at an anatomic site on the same day that a biopsy is carried out at a separate site, the services would be separately reportable by appending modifier -59 [Distinct procedural service] to the FNA code," Castillo says. Also notice that only the codes for aspiration (10021-10022), not evaluation of an FNA, are bundled with the biopsy codes. "In most cases, the pathologist may bill separately for evaluation for adequacy (88172) and interpretation of an FNA (88173) even if the FNA is followed by a biopsy," she says.

Same Analyte or Procedure Is Mutually Exclusive

Nearly 125 mutually exclusive code pairs were added to CCI 8.1, meaning that both services would not reasonably be performed for the same patient on the same day.

"Some of these mutually exclusive edit pairs are services that use different lab methods to arrive at similar information, and so would not likely be performed together," Dettwyler says. "For example, susceptibility tests by different methods such as agar dilution (87181); disk method (87184); enzyme detection (87186); macrobroth dilution (87188); and mycobacteria, proportion method (87190) are paired with each other." Other pairings of this nature include fecal occult blood tests (82270, 82274), various culture typing methods (87140, 87143, 87147, 87152, 87158), Herpes simplex tests (87273-87274 with 87528-87530), and Helicobacter pylori (87338-87339 with 78268 and 83013).

Other mutually exclusive edits in CCI 8.1 pair codes represent similar methods but are carried out on different sources. For example, 87149 (Culture, typing; identification by nucleic acid probe) is paired with each of the codes for infectious-agent detection by nucleic acid (DNA or RNA) (87470-87799). "Code 87149 describes nucleic acid probe technique for identification of an organism from a culture isolate, while the other codes describe nucleic acid probes for identification of an organism from the primary source, such as a blood smear, rather than a culture," Dettwyler explains.

Code Pairs Bundled by Terminology

Many new edit pairs appear to be based on bundling disparate services that use the same methodology/ terminology. "Sadly, the implication of many of these edit pairs seems to be that CMS anticipates some of the most egregious coding imaginable," Dettwyler says. "It is difficult to even classify these as 'bundled' services because they are actually completely separate services." In fact, the pairs are bundled under the CMS policy of "misuse of column-2 code [component] with column-1 code [comprehensive]." This policy states that CPT codes are written specifically to describe a procedure and also to avoid describing a similar service. Based on this policy, the two codes are considered bundled because "A CPT code should not be reported out of the context for which it was intended."

The comprehensive codes under this category along with a list of their component codes are:

Edits Bundle Specific Codes with Nonspecific

Many of the new edit pairs list a specific code as the comprehensive service and consider a similar service with "not otherwise specified" or "other" in the description as a component. For example, 84591 (Vitamin, not otherwise specified) is listed as a component code of each specific vitamin test in the chemistry section, such as 82306 (Calcifediol [25-OH Vitamin D-3]) and 84597 (Vitamin K). "Because of these edits, coders will have to use modifier -59 (Distinct procedural service)if, for instance, a test for B-12 (82607) and B-3, which does not have its own code and must be reported using 84591, is carried out for the same patient on the same day," Castillo says.

Similarly, nonspecific tumor antigen codes 86294 (Immunoassay for tumor antigen, qualitative or semiquan-titative [e.g., bladder tumor antigen]) and 86316 (Immunoassay for tumor antigen; other antigen, quantitative [e.g., CA 50, 72-4, 549], each) are listed as components of specific tumor antigen codes. These include quantitative tumor antigen tests for CA 15-3 (86300), CA 19-9 (86301) and CA 125 (86304).

CCI 8.1 also considers the "other source" culture codes (87070, 87071, 87073, 87075) to be components of the culture codes that list a specific source. This includes a bacterial blood culture code (87040), stool (feces) culture codes (87045, 87046), and urine culture codes (87086, 87088). "Again, coders must be aware of these new edit pairs and add modifier -59 to avoid denials if, for example, a physician requests a wound and blood culture on the same day," Dettwyler says.

Molecular Diagnostics Procedures Get Bundled

The molecular diagnostics codes (83890-83912) describe individual steps, such as extracting genetic material from various specimen sources, and isolating, manipulating and investigating specific nucleic acid sequences to detect mutations, often used to diagnose genetic disorders.

"Similar techniques may be used for culture or infectious-agent identification, but the molecular diagnostics codes were never intended to describe each of the steps of these comprehensive procedures," Dettwyler explains. Rather, the culture or infectious agent identification codes include all the steps used to reach the identification. For this reason, CCI 8.1 added four codes to the multitude of codes describing identification by nucleic acid that are already paired with the molecular diagnostic codes: