Pathology/Lab Coding Alert

CMS was quick to add Correct Coding Initiative (CCI) edit pairs for the new CPT 2003 codes in CCI version 9.0, providing clear coding restrictions for many services.

Many new edit pairs involve CPT Codes 2003 additions, such as codes for hematology, Pap smears, apheresis procedures and stem cell harvesting. "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. CCI Edits version 9.0 is effective Jan. 1 through March 31.

CCI Identifies Inappropriate Coding

" CCI Edits 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 they are reported together.

If the two services of a code pair are carried out as distinct and independent services that are medically necessary, however, 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. For clinical lab tests conducted more than once a day, use modifier -91 (Repeat clinical diagnostic laboratory test).

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. You should ensure that your lab does not indiscriminately override CCI edit pairs, and that when you do, you have appropriate documentation in the medical record to justify the claim of distinct procedural service.

New Hematology Section All Bundled Up

CPT 2003 overhauled the hematology codes, and CCI 9.0 quickly bundled them up. The two comprehensive blood count codes in CPT 2003 are 85025 (Blood count; complete [CBC], automated [Hgb, Hct, RBC, WBC and platelet count] and automated differential WBC count) and 85027 (Blood count; complete [CBC], automated [Hgb, Hct, RBC, WBC and platelet count]). "CCI 9.0 disallows reporting these two codes together and also bundles them with each of the components," Dettwyler explains. The components are as follows:

Finally, coders may not report together both the manual and automated code for a blood component. That means CCI 9.0 considers 85044 (Blood count; reticulocyte, manual) a component of 85045 (Blood count; reticulocyte, automated). Similarly, CCI bundles manual code 85032 (Blood count; manual cell count [erythrocyte, leukocyte, or platelet] each) as a component of the automated code for each cell type: 85041 (Blood count; red blood cell [RBC], automated), 85048 (Blood count; leukocyte [WBC], automated) and 85049 (Blood count; platelet, automated).

"The problem with these code pairs is that they bundle a code for multiple components (85032) with codes for each specific component. It is possible, for example, that a lab would carry out a manual platelet count and an automated RBC for the same patient on the same day," Dettwyler says. "Because this edit pair shows a 0 in the modifier column, a modifier will not override these edits."

Pap Smears Use One or the Other

New CPTcodes 88174 (Cytopathology, cervical or vaginal [any reporting system], collected in preservative fluid, automated thin layer preparation; screening by automated system, under physician supervision) and 88175 (... with screening by automated system and manual rescreening, under physician supervision) describe thin-layer prep diagnostic Pap tests. CCI 9.0 says you can't report these two codes together either you rescreened or you didn't. Nor can you report either new code with any other Pap smear by any other method or reporting system, whether diagnostic (88142-88154 and 88164-88167) or screening (G0123, G0143, G0144, G0145, G0147, G0148 and P3000).

"There should be no need to override these edits, and CCI 9.0 lists them with a 0 modifier indicator to ensure that you do not," Castillo says.

Learn New Bundles for Latest Category III and HCPCS Level II Codes

CCI 9.0 lists edit pairs for several new Category III (emerging technology) and HCPCS Level II codes. "Coders may actually find these bundles useful because they alert you to the fact that there are new codes with very similar definitions found outside the main sections of the CPT book," Castillo says. Do not report the following codes together, according to CCI:

CCI considers this procedure a component of 87903 (Infectious agent phenotype analysis by nucleic acid [DNA or RNA] with drug resistance tissue culture analysis, HIV 1; first through 10 drugs tested) and +87904 ( each additional 1 through 5 drugs tested).

In addition, you should not report two new HCPCS Level II codes for therapeutic stem cell freezing and thawing with CPTcodes for diagnostic cell freezing and thawing, according to CCI 9.0. The edits bundle as mutually exclusive codes G0265 (Cryopreservation, freezing and storage of cells for therapeutic use, each cell line) with 88240 (Cryopreservation, freezing and storage of cells, each cell line), and G0266 (Thawing and expansion of frozen cells for therapeutic use, each aliquot) with 88241 (Thawing and expansion of frozen cells, each aliquot).

The new G code for gastric tube placement, G0272 (Naso/oro gastric tube placement, requiring physician's skill and fluoroscopic guidance [includes fluoroscopy, image documentation and report]), is a component of several intubation services, according to CCI 9.0. These include codes for duodenal intubation and aspiration (89100-89105) and gastric tube intubation and aspiration (89130-89141).

Apheresis or Stem Cell Services Needles and E/M Included

A pathologist/hematologist may carry out any of the apheresis or stem cell/bone marrow harvesting procedures, but CCI 9.0 mandates that you pick one. Each of the new codes 36511-36516 (Therapeutic apheresis ...) describes the removal of a particular blood component (red blood cells, white blood cells, etc.) and the replacement of the patient's blood. "Aphysician would not normally perform apheresis for more than one component, so the fact that CCI lists each of these codes as mutually exclusive with the others should not be a problem for coders," Dettwyler says. Similarly, a patient's stem cell harvest will not be both allogenic and autologous, nor would a patient undergo stem cell and bone marrow harvest concurrently. That's why CCI 9.0 makes codes for these services (38205, 38206 and 38230) mutually exclusive edit pairs.

CCI 9.0 also bundles many injection, infusion and transfusion codes with many new apheresis and stem cell codes. You'll need to consult the edits to get the exact pairing of codes, but some of the services that CCI commonly bundles with many apheresis or stem cell services include the following:

Most coders know that you would not "unbundle" and separately report the needle-placement or infusion portion of an apheresis service. "Although clinical situations that require reporting these codes together are uncommon, you have to know how to override the edits if it is medically necessary to perform two of these procedures together for the same patient on the same day," Dettwyler says.

Many E/M codes also appear as components of each of the new apheresis and stem cell codes in CCI 9.0. "It is not uncommon for the pathologist to provide E/M services to the patient before, during and after an apheresis session," Dettwyler says. CMS considered many E/M codes bundled with deleted apheresis code 36520, however, and these new CCI edit pairs indicate the same status for the new apheresis codes. This means that physician oversight of the patient during the procedure, including such services as evaluating the patient's current physical condition, monitoring plasma flow and fluid replacement, and being available to intervene in the event of complications, is included in the apheresis service.

Infectious Agent Antigen Detection Methods Are Mutually Exclusive

CCI 9.0 adds a number of edit pairs that prohibit reporting together two codes for detecting the same organism. For example, don't report the following codes for "Infectious agent antigen detection by immunofluorescent technique" with other codes for the same organisms:

(Infectious agent antigen detection by enzyme immunoassay technique Influenza, A or B, each)

Don't report the following codes for "Infectious agent antigen detection by enzyme immunoassay technique" with other codes for the same organisms identified by "Infectious agent detection by nucleic acid " Many of these occur in a series of three codes for direct probe, amplified probe and quantification. The new code bundles are: