Pathology/Lab Coding Alert
Additions for Microbiology and Pathology Consultation
"Billing personnel need to be aware of these new edit pairs, as well as correct modifier usage, to avoid payment denials when these services are legitimately performed together for the same patient on the same day," says William Dettwyler, MT-AMT, coding analyst for Health Systems Concepts, laboratory coding and compliance consultants in Longwood, Fla.
CCI Identifies Inappropriate Coding
"The edit pairs represent services that are bundled (components of a more comprehensive service) or would not ordinarily be performed together for the same patient on the same day (mutually exclusive services)," says Laurie Castillo, MA, CPC, CPC-H, CCS-P, member of the National Advisory Board of the American Academy of Professional Coders, and president of Physician Coding and Compliance Consulting in Virginia. Medicare will not reimburse both services when reported together.
However, if the two services of a code pair are carried out as distinct and independent services that are medically necessary, Medicare may reimburse with the appropriate modifier. To indicate that codes represent separate services as opposed to unbundling of a single service, append modifier -59 (distinct procedural service) to override the edit.
Every code pair is assigned a "modifier indicator" of either "1," which means a modifier can be used with the pair, or "0," which means a modifier cannot be used. Practices should ensure that they do not indiscriminately override CCI edit pairs . When edit pairs are overridden, appropriate documentation must exist in the medical record to justify the claim of "distinct procedural service."
Microbiology Screening Codes
Nearly a third of the edits are mutually exclusive pairs that preclude reporting a screening culture with other culturing techniques. The two screening culture codes are 87081 (culture, presumptive, pathogenic organisms, screening only) and 87084 (... with colony estimation from density chart). The edits preclude reporting these two codes together or reporting either code with the following culture services:
Also, 87081 cannot be reported with 87071 (... quantitative, aerobic with isolation and presumptive identification of isolates, any source except urine, blood or stool), and 87084 cannot be reported with 87086 (... quantitative colony count, urine).
These edit pairs do not present a big obstacle, since screenings are generally ordered to look for a suspected organism and are not typically plated simultaneously for a separate culture isolation and presumptive identification. "For example, common screening cultures for organisms such as Streptococcus Group A or a gonococcus screen (for Neisseria gonorrhoeae) are reported with 87081, and are normally used as stand-alone tests," Dettwyler says. "If further identification is needed, tests such as 87077 (... aerobic isolate, additional methods required for definitive identification, each isolate) would be used, and are not subject to a CCI edit with the screening codes."
If a situation occurs involving conducting a screening culture and standard culture isolation with presumptive identification, the two services should be reported with modifier -59 to indicate that both were performed. For example, if a patient presents with a sore throat and earache, the physician may order a Strep screening culture from a throat swab (87081 for Group A Streptococcus) and an ear culture (87070 for presumptive identification, and 87077 if needed for definitive identification). All of these code pairs have a modifier indicator of "1."
New CCI Edit for Urine Culture
Many coders question how to report a bacterial urine culture with presumptive identification and a colony count. These services are described by two codes: 87088 and 87086. However, Dettwyler says, because only one culture may be involved for both services, concern arises over whether it is appropriate to report both.
The edits seem to make Medicare's position clear the two codes cannot be reported together. Codes 87086 and 87088 are listed as a mutually exclusive edit pair.
Also, urinalysis code 81007 (urinalysis; bacteriuria screen, except by culture or dipstick) is paired as a comprehensive code with component codes 87086 and 87088.
Culture Typing Methods Mutually Exclusive
Also new are a group of mutually exclusive edit pairs barring the reporting of culture typing by nucleic acid probe with culture typing by other methods. According to the list, 87149 (culture, typing; identification by nucleic acid probe) is not payable with the following other culture typing methods because they would not ordinarily be performed together:
New Edit Pairs for Pathology Consultation
Before version 8.0, pathology consultation services were a component of nearly 250 other pathology services. The 8.0 edits add this bundling to over 20 other pathology services.
Codes 80500 (clinical pathology consultation; limited, without review of patient's history and medical records) and 80502 (... comprehensive, for a complex diagnostic problem, with review of patient's history and medical records) are components of the following services:
Reporting pathology consultation with other fetal lung maturity tests (83661-83662) was disallowed under earlier edits. The prohibition has been expanded to these methods as well:
CCI 8.0 also expands the existing pairing of various infectious agent antigen detection methods with pathology consultation codes.
Previous versions disallowed reporting many immunofluorescent techniques for infectious agent antigen detection (87260, 87265, 87270, 87272, 87274, 87276, 87278, 87280, 87285, 87290, 87299) with the pathology consultation codes. The list now includes all codes in the range 87260-87300.
The edits do not pair pathology consultation codes with the enzyme immunoassay techniques for infectious agent antigen detection (87301-87451). However, reporting a consultation with many of the nucleic acid probe techniques (87470-87799) and immunoassay with direct optical observation techniques (87810-87899) was previously prohibited, and is now expanded to include
the following:
Pathology consultation codes 80500 and 80502 were paired with the following:
New Edits Pair FNA, Breast Biopsy
Some breast biopsy codes are bundled with imaging and FNA codes. Unfortunately, these pairs use the FNA codes that were deleted from CPT 2002 (88170-88171) rather than the new codes that replaced them (10021-10022). The following breast biopsy codes are the comprehensive service to FNA codes 88170 (now 10021, fine needle aspiration; without imaging guidance), 88171 (now 10022, ... with imaging guidance) and 88172 (cytopathology, evaluation of fine needle aspirate; immediate cytohistologic study to determine adequacy of specimen[s]):
Additionally, 45342 (imaging guided sigmoidoscopy with FNA biopsy) is bundled with the image guided FNA code (listed in CCI edits as 88171, but actually 10022).
Pathology/Lab Coding Alert
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Additions for Microbiology and Pathology Consultation
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