Pathology/Lab Coding Alert

CPT^® 2019 codes top restriction list.

The massive Correct Coding Initiative (CCI) version 25.0 update boasts almost 46,000 new edit pairs, and nearly 8,300 of those come from the 80000-level CPT^® codes alone. That means you have a lot to learn to avoid claims denials for code bundles that became effective Jan. 1.

As usual for first-quarter CCI updates, many of the edits focus on new CPT^® codes. Read on for some significant CCI know-how to ensure you’re billing correctly for your lab, because “it is important to review the edits and apply them as soon as possible,” advises Arnold Beresh, DPM, CPC, CSFAC, in West Bloomfield, Michigan.

Focus on These FNA Edits

You’ve got a bunch of edits to learn regarding new fine needle aspiration (FNA) codes +10004 (Fine needle aspiration biopsy, without imaging guidance; each additional lesion (List separately in addition to code for primary procedure)-10008 (…, including fluoroscopic guidance; each additional lesion (List separately in addition to code for primary procedure)).

Restrict unbundling: CCI 25.0 creates edit pairs with a modifier indicator of “0” that bundle new codes +10004-10008 with the following codes: 36591 (Collection of blood specimen from a completely implantable venous access device), 36592 (Collection of blood specimen using established central or peripheral catheter, venous, not otherwise specified), and 96523 (Irrigation of implanted venous access device for drug delivery systems). The “0” modifier indicator means that you cannot override these edits under any circumstances.

Modifier indicator “1”: You’ll also find multiple codes bundled into add-on FNA codes +10004 and +10006 that carry a modifier indicator of “1,” such as the following:

• 10035 (Placement of soft tissue localization device(s) (eg, clip, metallic pellet, wire/needle, radioactive seeds), percutaneous, including imaging guidance; first lesion)
• 36000 (Introduction of needle or intracatheter, vein)
• 61650 (Endovascular intracranial prolonged administration of pharmacologic agent(s) other than for thrombolysis, arterial, including catheter placement, diagnostic angiography, and imaging guidance; initial vascular territory).

CCI 25.0 also creates edit pairs with a modifier indicator of “1” for several services bundled with new primary FNA codes 10005, 10007, and 10008, such as the following:

• 10021 (Fine needle aspiration; without imaging guidance; first lesion)
• 19281 (Placement of breast localization device(s) (eg, clip, metallic pellet, wire/needle, radioactive seeds), percutaneous; first lesion, including mammographic guidance)
• 76000 (Fluoroscopy (separate procedure), up to 1 hour physician or other qualified health care professional time).

Possibly unbundle: When the modifier indicator is “1,” you may be able to report both codes of an edit pair under certain, well documented circumstances. To override the edit pair and report both codes, when appropriate, you should use a modifier such as 59 (Distinct procedural service), according to Mary I. Falbo, MBA, CPC, president and CEO of Millennium Healthcare Consulting Inc. in Lansdale, Pennsylvania.

Round up Molecular Pathology Edit Pairs

With CPT^® 2019’s overhaul of BRCA1 and BRCA2 genetic test codes (see “Update BRCA1, BRCA2 Test Codes” in Pathology/Lab Coding Alert Vol. 20, No. 2), plus nearly 50 new Tier 1 molecular pathology codes, you can expect hundreds of new edit pairs restricting how you report these services.

Avoid these BRCA bundles: You should never bill any of the new or revised BRCA codes 81162-81217 (BRCA1 [and/or] BRCA 2 gene analysis…) (some codes out of numerical sequence) with themselves when the two codes include testing for some of the same variants. CCI 25.0 enforces that restriction with a “0” modifier indicator for the following edit pairs:

• Column 1 code 81162 with the following column 2 codes: 81163, 81164, 81165, 81166, 81167
• Column 1 code 81163 with the following column 2 codes: 81164, 81165, 81126
• Column 1 code 81164 with the following column 2 codes: 81166, 81167, 81215, 81217
• Column 1 codes 81165 and 81166 with column 2 code 81215
• Column 1 code 81167 with column 2 code 81217.

Shun Tier 1 with procedure codes: In addition to new BRCA1/BRCA 2 codes, CPT^® 2019 adds many new codes for specific molecular pathology tests listed in alphabetical order by gene name throughout the Tier 1 section, ranging from 81171 (AFF2… gene analysis …) to 81333 (TGFBI … gene analysis…) (some codes out of numerical sequence). CCI 25.0 bundles these new codes with the following codes that describe method codes other gene analyses in column 2, such as the following:

• 80500-80502 (Clinical pathology consultation …)
• 84311 (Spectrophotometry, analyte not elsewhere specified)
• 87140-87158 (Culture, typing …)
• 87471-87801 and G0476 and 0500T (Infectious agent detection by nucleic acid (DNA or RNA) …)
• 88271-88291 (Molecular cytogenetics …)
• 88365-88377 and 0009U (In situ hybridization … [ISH])
• G0452 (Molecular pathology procedure; physician interpretation and report).

These edits have a “1” modifier indicator, meaning that you can override the edit pairs if the codes describe distinct procedures for different specimens.

Beware Chemistry-Code Restrictions

Labs should be aware of the following CCI edit pairs with a “0” modifier indicator for the following new chemistry and codes:

• New-code 82642 (Dihydrotestosterone (DHT)) is a column 2 code with 80327 and 80328 (Anabolic steroids…)
• New-code 83722 (Lipoprotein, direct measurement; small dense LDL cholesterol) is a column 2 code with 83700-83704 (Lipoprotein, blood…).

You should not override these edit pairs for any reason.

Bottom line: You can avoid claims denials by obeying the preceding CCI restrictions, as well as following rules about when and how to override any of the edit pairs. In addition to the code bundles discussed here, you should be aware that CCI 25.0 includes many more bundles relevant to labs that we haven’t discussed, especially involving new Proprietary Laboratory Analyses (PLA) codes in the range 0001U to 0061U. You can find the complete list of CCI edits at www.cms.gov/Medicare/Coding/NationalCorrectCodInitEd/NCCI-Coding-Edits.html.