Pathology/Lab Coding Alert

CMS opened the door to the clinical-lab-test reimbursement process, allowing a glimpse at coding and reimbursement changes for 2003. What's coming is a significant overhaul of hematology codes and an improving process for laboratory comment on pricing decisions.

Under federal legislation, CMS recently held its second annual public hearing for changes to the Clinical Laboratory Fee Schedule (CLFS). The AMA's CPT Editorial Panel moved up the new-code release date to June for clinical lab procedures, allowing public comment on pricing before CMS sets Medicare lab procedure payments. The new codes are available on the Internet by selecting "2003 New Laboratory Tests" at http://cms.hhs.gov/ medicare/hcpcs/labtests.pdf.

Note that CMS held the public meeting only to hear comments on pricing, not the codes themselves. You can expect the published AMA CPT 2003 in October and the final 2003 CLFS by November.

CLFS Payment Recommendations Heard

CMS sets payment for new CPT Codes by either "crosswalking" pricing the new code the same as an existing, similar code or "gap-filling" allowing individual carriers to price the new code for a year before evaluating that pricing and setting a rate. Several professional groups commented on pricing for the new CLFS codes at the CMS public meeting.

"The College of American Pathologists [CAP] recommended cross-walking the majority of the new clinical lab codes this year because they did not involve novel or unique technologies," says Stephen N. Bauer, MD, FCAP, CAP's representative to the AMA CPT Advisory committee.

Compared to CMS' "dry run" meeting last year, Bauer comments, "There was more discussion at this meeting." He maintains that CMS' new process is worthwhile, allowing interested parties to have direct input and discussion before CLFS pricing is set.

Hematology Codes Slated for Overhaul

"Hematology and coagulation codes 85007-85048 entail multiple deletions, additions and revisions in CPT 2003, changing the basic structure of the section," says William Dettwyler, MT-AMT, coding analyst for Health Systems Concepts, a laboratory coding and compliance consulting firm in Longwood, Fla.

Now, CPT codes 85021-85031 describe different blood count services, with varying combinations of hemogram (red blood cells [RBC], white blood cells [WBC], hemoglobin [Hgb], hematocrit [Hct] and indices), differential WBC count, and/or platelet count, with a distinction between manual and automated tests. Changes slated for CPT 2003 eliminate this structure by deleting most of these codes and radically altering the remaining definitions. Gone are any references to hemogram the remaining codes refer to complete blood count (CBC), defined as Hgb, Hct, RBC, WBC and platelet count. This represents a terminology change such that CBC now includes the platelet count but not the differential count, Dettwyler says. Only two codes from the range 85021-85031 remain in CPT 2003:

Dettwyler also notes that by deleting 85024 (Blood count; hemogram and platelet count, automated, and automated partial differential WBC count [CBC]) and referring coders to 85025, a code distinction between partial or complete differential WBC no longer exists. "The distinction has been a problem in the past because the CBC with partial differential (85024) often paid more (higher Medicare national cap) than the CBC with complete differential (85025), so some labs were tempted to downcode or choose equipment on the basis of reimbursement," he says.

To report an automated differential WBC without a CBC, you should use new code 8500x (Blood count; automated differential WBC count). Report blood smears with or without differential WBC as:

Codes for the CBC component tests are as follows:

"Based on general coding principles, you should not separately report the individual tests if there is a single code that includes all the components," Dettwyler says. "For example, report a CBC as 85027; don't individually report each automated component test [Hct (85014), Hgb (85018), RBC (85041), platelet (8504x), WBC (85048)]."

You should also avoid reporting the code for manual erythrocyte, leukocyte or platelet count (8503x) with the codes for automated counts of these same components (RBC [85041], leukocyte [85048], platelet [8504x]), Dettwyler says. "Once these codes are active, look for AMA coding direction or CCI edits to confirm these coding restrictions," he says.