Pathology/Lab Coding Alert

Follow payer preference for billing success.

When your lab repeats a clinical diagnostic lab test or your pathologist examines multiple specimens, you need to know the tricks of the trade to avoid payers shutting down your claim.

Problem: When you use the same CPT^® code more than once on the same date — even when it’s medically necessary — payers may erroneously think it’s a “duplicate” bill and funnel you into the long process of dealing with a denial.

Study the following tips and scenarios to make sure your lab gets paid the first time for services rendered — without needing to appeal denied claims.

Check Out Useful Modifiers

Medicare and other payers may accept your bill and pay for repeat services or distinct procedures listed with the same CPT^® code if you use the correct modifier.

Here’s why: “Modifiers … enable health care professionals to effectively respond to payment policy requirements established by other entities,” according to CPT^® instruction.

When you are submitting claims for multiple instances of services or procedures, your claims should include an appropriate modifier to indicate that the service or procedure is not a duplicate, according to Arlene Dunphy, CPC, provider outreach and education consultant with the Part B Medicare Administrative Contractor (MAC) National Government Services (NGS) in a recent webinar “How to Avoid Duplicate Claim Denials.” Other MACs have similar policies, and you should check with your MAC for specific rules.

Key: Depending on the claim and the code(s) billed, the appropriate modifier will allow your claim to get processed and paid.

Options: You might use the following modifiers in your lab and pathology billing for repeat/multiple services billed with the same code:

• 76 (Repeat Procedure or service by same physician or other qualified health care professional)
• 77 (Repeat procedure by another physician or other qualified health care professional)
• 91 (Repeat clinical diagnostic laboratory test)
• 59 (Distinct procedural service) or one of the following instead:
  o XE (Separate encounter, a service that is distinct because it occurred during a separate encounter)
  o XP (Separate practitioner, a service that is distinct because it was performed by a different practitioner)
  o XS (Separate structure, a service that is distinct because it was performed on a separate organ/structure)
  o XU (Unusual non-overlapping service, the use of a service that is distinct because it does not overlap usual components of the main service)

Turn to 91 for Clinical Lab

If your lab repeats the same clinical diagnostic test at the physician’s request for medical reasons, you should report the second and each subsequent test code with modifier 91.

For instance: If the physician orders three sodium blood tests on the same date for a post-surgical patient under treatment for hyponatremia, you should bill the testing as 84295 (Sodium; serum, plasma or whole blood) for the first test, and 84295-91 for each subsequent test.

Panel problem: Sometimes the lab performs a panel test, and then the clinician orders a repeat test of one panel component. Medicare and most other payers will reject a claim with a panel test code and a separate code for one of the components of the panel as duplicate billing.

For example, a patient presented to the emergency room with rapid heartbeat and confusion and the physician ordered a basic metabolic panel (with total calcium). After finding a glucose level at 55 mg/dL, the clinician ordered a glucagon injection followed by a repeat glucose test.

Do this: You should bill the preceding example as 80048 (Basic metabolic panel (Calcium, total) This panel must include the following:

• Calcium, total (82310)
• Carbon dioxide (bicarbonate) (82374)
• Chloride (82435)
• Creatinine (82565)
• Glucose (82947)
• Potassium (84132)
• Sodium (84295)
• Urea nitrogen (BUN) (84520))

Then you should bill the subsequent glucose test as 82947 (Glucose; quantitative, blood (except reagent strip) with modifier 91.

Series: If a more specific code describes a series of repeat lab tests, you should use the specific code. For instance, report a glucose tolerance test as 82951 (Glucose; tolerance test [GTT], three specimens [includes glucose]), not as 82947 plus subsequent testing as 82947-91.

Caution: You should not bill multiple units of a test with modifier 91 if the lab repeats a test due to testing problems or to confirm initial results. Those situations earn just a single unit of the test code.

Entertain Alternatives for Multiple Procedures

Pathologists may examine multiple tissue specimens from the same date of service. Or physicians may request a culture from different body sites on the same date. When situations result in billing the same code multiple times, you’ll need a modifier to tell the tale that this is not a duplicate bill for the same service.

Example 1: Your pathologist may receive and examine three, separately identified skin lesion specimens from different body sites on the same date. “The correct coding for that work is three units of 88305 (Level IV - Surgical pathology, gross and microscopic examination … skin, other than cyst/ tag/debridement/plastic repair …),” says R.M. Stainton Jr., MD, president of Doctors’ Anatomic Pathology Services in Jonesboro, Arkansas.

Using modifiers — or not — you have the following multiple ways to code this scenario:

• List 88305 x 3 on a single claim line
• List 88305 on one claim line, followed by 88305-59 on subsequent claim lines for each additional lesion
• List 88305 on one claim line, followed by 88305-XS on subsequent claim lines for each additional lesion
• List 88305 on one claim line, followed by 88305-76 on subsequent claim lines for each additional lesion

How to choose: Although none of the preceding options are wrong, not all of them will get you paid by a specific insurer.

Each MAC and each private insurer will have their own policies and preferred ways to handle situations like this. Your best bet is to know what your payer prefers and code the situation that way. Make sure you have documentation that you’re billing truly separate procedures before filing your claim.