Pathology/Lab Coding Alert

Catch some interpretation bundles, too.

CMS wants to make sure you know how NOT to report your pathologist’s service to interpret or consult on the results of a molecular pathology test.

By adding over 350 edit pairs in the National Correct Coding Initiative (CCI) version 23.1, effective April 1, 2017, CMS essentially restricts how you can code for the pathologist’s work to provide clinical context for molecular analyses.

Don’t Misuse 80500, 80502

The majority of the new edit pairs bundle virtually all molecular testing with 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) as column 2 codes. That includes levels 1 and 2 molecular pathology codes (81161-81383 and 81400-81408), genomic sequencing procedures (81410-81479), and Multianalyte Assays with Algorithmic Analyses (MAAAs, 81490-81595).

Turn to G0452: If a pathologist’s interpretation is medically necessary for one of these bundled molecular tests, you already have an appropriate code option to capture that service — G0452 (Molecular pathology procedure; physician interpretation and report).

CMS pays for most of the molecular test codes on the Clinical Laboratory Fee Schedule (CLFS). If the pathologist needs to provide a physician professional interpretation for the test results to be clinically useful, then you should report G0452 in addition to the code for the specific molecular pathology test.

In other words, G0452 is the appropriate code choice to report the physician interpretation of a molecular test, rather than either of the pathologist consultation codes 80500 or 80502. That’s why “the CCI edits bundling the molecular codes with 80500 and 80502 probably won’t create a billing problem for your lab,” according to William Dettwyler, MT AMT, president of Codus Medicus, a laboratory coding consulting firm in Salem, Ore.

Caution: CPT^® provides a different code for pathologist interpretation of cytogenetic studies described by codes in the 88230-88289, and that code is 88291 (Cytogenetics and molecular cytogenetics, interpretation and report). Don’t use 88291 instead of G0452 for interpretation of molecular pathology and genomic sequence tests.

Look Out for More MAAA Bundles

In addition to bundling MAAA codes with 80500 and 80502, CCI 23.1 also restricts using many of the MAAA codes with G0452 or 88291.

Here’s why: Most of the MAAA codes include an algorithm that provides the clinical significance of the test results, so the pathologist should not need to provide additional interpretation of these studies.

Know modifier exception: The modifier indicator for most of these new CCI edit pairs is “1,” which means that you can override the edit pair when appropriate. For instance, if the pathologist provides a legitimate pathology consultation service in association with a different test on the same date as a molecular pathology procedure, you’ll still have a problem getting paid for all the services based on the CCI edits. In that case, you can legitimately override the edit pair using a modifier such as 59 (Distinct procedural service), because the 80500 consultation is for a service other than the molecular test.