Pathology/Lab Coding Alert

Uncover secrets of PTP modifiers and more.

Confusion over Medicare’s National Correct Coding Initiative (CCI) program can thwart your clean claims -- and cost you pay that your lab deserves.

Refresh your CCI fundamentals and learn some new tricks with our experts’ advice to smooth the way to ethically maximize reimbursement and avoid denials.

Identify PTP Edits for Clarity

Fun fact: CCI edits are more than 20 years old. In 1996, CMS implemented Procedure-to-Procedure (PTP) edits. These edits indicate the CPT^® and HCPCS code pairs you should normally not report together. CMS updates its PTP edits quarterly. If you’ve been in the coding game a while, you may remember the days when CMS called these edits Column One/Column Two edits and Mutually Exclusive edits.

As an example, refer to the PTP lab code pairs in the table below. You can see that 88342 (Immunohistochemistry or immunocytochemistry, per specimen; initial single antibody stain procedure) is a column 2 code for 88344 (… each multiplex antibody stain procedure). Also notice that 80048 (Basic metabolic panel [Calcium, total], This panel must include the following: Calcium, total [82310]; Carbon dioxide [bicarbonate] [82374]; Chloride [82435]; Creatinine [82565]; Glucose [82947]; Potassium [84132]; Sodium [84295]; Urea nitrogen [BUN] [84520]) is a column 2 code with 80053 (Comprehensive metabolic panel, This panel must include the following: Albumin [82040], Bilirubin, total [82247]; Calcium, total [82310]; Carbon dioxide [bicarbonate] [82374]; Chloride [82435]; Creatinine [82565]; Glucose [82947]; Phosphatase, alkaline [84075] Potassium [84132]; Protein, total [84155]; Sodium [84295]; Transferase, alanine amino [ALT] [SGPT] [84460]; Transferase, aspartate amino [AST] [SGOT] [84450]; Urea nitrogen [BUN] [84520]).

Consequence: If you report both codes of a PTP pair for the same patient on the same date of service, the Column 1 code is eligible for payment, but your payer will deny the Column 2 code. For instance you’d get paid for the comprehensive metabolic panel (80053) but not the basic metabolic panel (80048).

Understand PTP Modifier Indicators to Deepen Your Knowledge

Although PTP edits show which CPT^® codes you should not report together, under some circumstances, you can use a modifier to override the edits. To learn whether an override is allowed, you should look in the “modifier indicator” column, which contains 0, 1, or 9.

Learn what the following modifier indicators mean to ensure you use them correctly:

• 0: You cannot use a modifier to override the edit under any circumstances
• 1: You can use a modifier to override the edit when appropriate, but the documentation and clinical circumstances must always support that action, such as for services for separate sites or sessions
• 9: The modifier indicator is irrelevant, such as when CMS deletes an edit retroactively, meaning it’s as if the edit never existed.

Based on the previous examples in the table, you can see how this impacts your coding and reimbursement.

For instance: If your lab performs a PIN-4 and an EGR stain on a prostate biopsy specimen, you can report both services because they represent two unique qualitative immunohistochemistry (IHC) stains. The problem is the CCI edit that bundles the single-antibody EGR stain (88342) as a column 2 code with the PIN-4 multiplex stain that uses multiple antibodies such as P504S, P63, CK903 (88344).

Do this: Add an appropriate modifier such as 59 (Distinct procedural service) to 88342 to override the edit pair and get payment for both the 88342 and 88344 IHC stains.

On the other hand: You should never bill together 80048 and 80053 for the same patient on the same day. That’s because the two codes have a “0” modifier indicator. In this case, the reason for the edit pair and the no-override makes sense: the 80048 and 80052 panels include many of the same analytes, so there would be no reasonable circumstance that would warrant medical necessity for both tests on the same day.

Learn more: Visit www.cms.gov/Medicare/Coding/NationalCorrectCodInitEd/index.html and see the menu on the left side of the Web page to find the PTP edit tables. To read the helpful guidelines in the National Correct Coding Initiative Coding Policy Manual for Medicare Services, look under “Downloads” on the same Web page.

Get Up to Speed on CCI Edits to Protect Your Practice

Check out these helpful tips from our pros to learn how you can prepare for and apply each new release of the CCI edits.

Tip 1: Find reliable sources for your info. “I’m always compiling new information with supporting documentation before I change my coding practices/procedures,” says Christina Neighbors, MA, CPC, CCC, coding quality auditor for Conifer Health Solutions, Coding Quality & Education Department. “I never immediately change the coding practices/procedures without three references supporting any guidance or changes.”

Tip 2: Take time to review quarterly CCI changes and communicate findings with your lab. Practices should have a point person to take the uninterrupted time to go over the changes and then share them with the staff, says Terry A. Fletcher, BS, CPC, CCC, CEMC, CCS-P, CCS, CMSCS, CMCS, CMC, ACS-CA, SCP-CA, healthcare coding educator, auditor, and management consultant of Terry Fletcher Consulting.

Tip 3: Review the edits before you submit a claim. “My advice is to always check the NCCI edits for each and every procedure reported,” says Dolly Perrine, CCS-P, CPC, CPC-I, CUC, CPMA, auditor and educator of professional services at St. Charles Health System in Bend, Ore. If you don’t, you could trigger a claims denial or leave money on the table by missing appropriate opportunities to use a modifier to unbundle an edit pair.

Tip 4: Remember documentation is key to supporting override. “If documentation supports reporting both procedures (with modifier), and one procedure is denied, always appeal,” says Perrine. “I have found that if I have supporting documentation and the claim is denied due to bundling, if I appeal, it would most always be paid. I’m aware that it takes additional time to appeal, but once again, that’s money left on the table.”