Pathology/Lab Coding Alert

This issue of Pathology/Lab Coding Alert includes an insert that is a description of the seven compliance-program guidelines suggested by the Office of the Inspector General (OIG). The policies and procedures that are part of a good compliance program have a direct impact on coding and billing. For example, a well- designed requisition form will help the physician identify exactly which test he or she means to order, which in turn tells the coder which code to bill.

Requisition Forms

With the guidance of individuals familiar with coding requirements, requisition forms should be designed to capture the correct information to facilitate appropriate ordering of tests, states Thomas Kent, CMM, president of Kent Medical Management, a coding and practice management firm located outside of Washington, D.C. For example, when a physician orders a Pap smear, the form should prompt him or her to designate whether it is a diagnostic test ( 88142-88154 and 88164-88167) or a screening test (P3000, G0123, G0143-G0145, G0147 G0148,) and remind him or her of the frequency constraints for screening Pap smears. The requisition also should require the physician to submit diagnosis information as documentation of medical necessity, he says.

Advance Beneficiary Notices (ABNs)

Give ABNs to patients only when there is a genuine doubt that the test the physician ordered will be covered by Medicare, advises Kent. Thats why it is important for individuals with knowledge of coding and reimbursement to be involved in developing the procedure that identifies when ABNs should be given.

Proceeding with the previous example, if a physician ordered a screening Pap smear using a diagnosis that indicates low risk (V76.2, special screening for malignant neoplasm; cervix) but the patient indicates that she has had a Pap smear within the past three years, you should ask her to sign an ABN.

Assigning Procedure Codes (HCPCS and CPT)

A big issue in compliance is that coders must ensure that the billing code accurately describes the service that was ordered and provided, says Kent. They must avoid upcoding to maximize reimbursement because upcoding can easily lead to an audit. For example, examination of an epidermoid inclusion (706.2) would be coded 88304 (level III- surgical pathology , gross and microscopic examination; skin - cyst/tag/debridement). Coding 88305 (level IV- surgical pathology, gross and microscopic examination; skin, other than cyst/tag/debridement/plastic repair), which has a higher reimbursement but does not accurately describe the specimen, would be considered upcoding.

Kent continues, Coders also must ensure that they avoid unbundling services. For example, if a patient undergoes surgery for a malignant neoplasm of the colon (153.x) and the pathologist receives a total colon resection with attached pericolonic tissue including lymph nodes, the correct procedure code would be 88309 (level VI - surgical pathology, gross and microscopic examination; colon, total resection). Coding separately for the attached lymph nodes (88307 level V - surgical pathology, gross and microscopic examination; lymph nodes, regional resection) would be considered unbundling, because associated lymph nodes generally are considered a part of the resected 88309 specimen, says Kent.

Assigning Diagnosis/Symptom Codes (ICD-9)

Medicare carriers have authority to develop local medical-review policies (LMRP), which may restrict reimbursement of lab procedures to certain conditions or diagnoses. Kent suggests that lab policies need to ensure that the ordering physician supplies the appropriate documentation and diagnosis codes to support the tests being ordered. Laboratories should educate physicians regarding the reporting requirements.

Policies also should restrict coding practices, such as using the diagnosis from earlier dates of service or assigning diagnosis codes to trigger reimbursement without appropriate physician documentation, says Kent. For example, if a physician ordered a lipid panel (80061) for screening purposes with no signs and symptoms indicating medical necessity for the test, assigning a diagnosis of a lipid metabolism disorder based on test results (272.x) to effect reimbursement would be fraudulent. Policies should require coders to obtain diagnostic information from the ordering physician and accurately translate narrative diagnosis into ICD-9 codes, he concludes.