Pathology/Lab Coding Alert

CPT 2001 contains many changes for pathology/laboratory coding. The section includes 57 new, 66 revised and 17 deleted codes, as well as some changes to the narrative instructions. pathology Coder should learn the details of the new and changed codes to make sure they receive the appropriate reimbursement.

Sentinel Lymph Node, FNA and Frozen Section Coding Clarification

Probably the most important changes for anatomic pathology in CPT 2001 involve coding for sentinel lymph nodes, fine needle aspiration (FNA) and frozen sections, says Laurie Castillo, MA, CPC, CPC-H, CCS-P, a member of the national advisory board of the American Academy of Professional Coders (AAPC) and president of its Northern Virginia Chapter.

Sentinel lymph node has been added to the specimen list for 88307 (level V surgical pathology, gross and microscopic examination) in CPT 2001. Although sentinel lymph node biopsy requires more extensive study for occult metastases, there previously was no way to capture the increased level of service, Castillo says. In fact, some coders were hesitant to code separately for the sentinel node at all, even as 88305 (level IV lymph node, biopsy), because the procedure is often carried out for a patient undergoing a radical mastectomy (88309, level VI breast, mastectomy - with regional lymph nodes), which lists the nodes as included in the specimen. The addition of the sentinel lymph node to 88307 makes it clear that the sentinel node is considered a separate specimen, and should be coded separately from any other surgical specimen, Castillo says.

Codes for FNA were modified in CPT 2001 to clarify which portion of the procedure is represented by each code. The words with or without preparation of smears were removed from 88170 (fine needle aspiration; superficial tissue [e.g., thyroid, breast, prostate]), 88171 (... deep tissue under radiologic guidance) and CPT 88172 (cytopathology, evaluation of fine needle aspirate; immediate cytohistologic study to determine adequacy of specimen[s]).

Codes 88170 and 88171 are used to report the aspiration of fluid or tissue through the needle, which may or may not be carried out by the pathologist, Castillo explains. Code 88172 describes the pathologists immediate evaluation of the aspirate to determine if the specimen is adequate, or if more cells must be aspirated. The final interpretation and report is coded 88173. A pathologist may report the three codes together if all three services are provided: 88170 or 88171 for removing the specimen, 88172 to determine adequacy, and 88173 for interpretation.

A change in wording for frozen sections clarifies another issue that has confused coders in the past. The words first tissue block were added to 88331 (pathology consultation during surgery; first tissue block, with frozen section[s], single specimen.) This makes it clear that the first tissue block for frozen sections from a single specimen is reported as 88331, and any subsequent tissue blocks from the same specimen are reported as 88332 (... each additional tissue block with frozen section[s]). If only one block is prepared for frozen sections for a given specimen, use code 88331, Castillo says.

Change and Addition of Codes Differentiate Tests

Many new and revised pathology and laboratory codes involve changes intended to differentiate between tests on the basis of substrate, methods or results, explains Kenneth Wolfgang, MT (ASCP), CPC, CPC-H, director of coding and analysis for National Health Systems Inc., a coding consultation company in Camp Hill, Pa. Laboratory tests often vary depending on what body substance is examined (e.g., blood, breath, urine), how the test produces the measurement (e.g., colorimetric, enzyme immunoassay), or what specific component is assayed (e.g., total or biologically reactive).

Code changes and additions in this category are intended to give coders more specific codes to reflect current practice and differentiate similar but distinct laboratory tests. The following code changes and additions fall into this category:

1. Tumor markers. One of the most significant changes in this category involves reporting of tumor markers, Wolfgang says. In the past, code 86316 was used to report any immunoassay for a tumor antigen. The problem was, some markers were covered by insurance based on their clinical usefulness for certain cancers, and others were not. The code itself did not provide adequate description of what assay was done, creating coverage problems.

CPT 2001 adds four new codes that specify the type of test and tumor marker being identified. Code 86316 was changed to represent any other antigen. The codes are as follows:

86294 immunoassay for tumor antigen, qualitative or semiquantitative (e.g., bladder tumor antigen)

86300 immunoassay for tumor antigen, quantitative: CA 15-3 (27.29)

86301 immunoassay for tumor antigen, quantitative: CA 19-9

86304 immunoassay for tumor antigen, quantitative: CA 125

86316 immunoassay for tumor antigen; other antigen, quantitative (e.g., CA 50, 72-4, 549), each.

2. Carbamazepine. The word total was added to the description of 80156 (carbamazepine; total) to describe a test for the total measure of this therapeutic anticonvulsant. A new code, 80157 (carbamazepine; free), has been added to describe the test for the free component.

3. Bilirubin. Code 82251 (bilirubin; total AND direct) has been deleted. Existing codes 82247 (bilirubin; total) and 82248 (bilirubin; direct) should be used separately to report the distinct tests, or together if both aspects of bilirubin are tested.

4. Codes 82270, 86683 and 83033. A phrase distinguishing the testing method was added to 82270 (blood, occult, by peroxidase activity [e.g., guaiac]; feces, 1-3 simultaneous determinations.) New direction in the text following the code indicates that fecal hemoglobin detection by immunoassay should be reported using 86683 (antibody; hemoglobin, fecal). This new code should also be used to report quantitative fetal hemoglobin, fecal, rather than 83033 (hemoglobin; F (fetal), qualitative), which was changed to remove the reference to fecal specimen.

5. Cryoglobulin tests. Language was added in CPT 2001 to differentiate between qualitative and quantitative cryoglobulin tests. Code 82595 was changed to read cryoglobulin, qualitative or semi-quantitative (e.g., cryocrit), and text was added below the code with direction to see codes 82784 and 82785 for quantitative tests.

6. Glucose testing. Glucose testing is differentiated in CPT 2001 based on the substrate tested. New code 82945 is used to report glucose, body fluid, other than blood. Code 82947 was amended to specify glucose; quantitative, blood (except reagent strip). The test using the reagent strip remains coded as 82948 (... blood, reagent strip).

7. Helicobacter pylori activity. Several laboratory methods have evolved over the years for detecting helicobacter pylori activity, and revisions in CPT 2001 reflect those changes, Wolfgang says. Code 83013 was changed to indicate the test method involved. The altered code reads helicobacter pylori; analysis for urease activity (mass spectrometry). New text under the code directs users to report existing codes 87338 for H. pylori, stool, 78267 and 78268 for H. pylori, liquid scintillation counter, and new code 87339 for infectious agent antigen detection by enzyme immunoassay technique, qualitative or semiquantitative, multiple step method; helicobacter pylori.

8. Fetal lung maturity tests. Different methods for testing fetal lung maturity have also evolved, resulting in revised and new codes for 2001. Code 83661 (fetal lung maturity assessment; lecithin sphinogomyelin ratio [L/S] ratio) contains new language to indicate that it is one of several tests for fetal lung maturity assessment. The other tests for fetal lung maturity assessment are reported with existing code 83662 for foam stability test and new codes 83663 (... fluorescence polarization) and 83664 (... lamellar body density). Direction has been added to the text of 83664 For phosphatidylglycerol, use 84081.

9. Organic acid tests. Reporting of organic acid tests changes under CPT 2001 with the addition of 83921 (organic acid, single, quantitative) and the change indicating total for 83918 (organic acids; total, quantitative, each specimen).

10. Prostate specific antigen tests. Separate codes are already available to report prostate specific antigen (PSA) total (84153) and free (84154). These two measures have been used in the past to determine a calculated value of complexed PSA, which appears to be a more significant indicator for prostatic carcinoma. A new lab test is now available for direct determination of complexed PSA, and it is to be reported using the new code 84152 (PSA; complexed [direct measurement]). For PSA screening for Medicare, continue to use G0103 (prostate cancer screening; PSA, total).

11. Code 85535-85536. Code 85536 (iron stain, peripheral blood) has been added, as distinct from the existing code 85535 (iron stain [RBC or bone marrow smears]). Also, direction following the code states, for iron stains on bone marrow or other tissues with physician evaluation, use 88313.

12. Cardiolipin antibody testing. Coding for cardiolipin antibody testing has changed to accommodate the reporting of more specific results. In the past, a cardiolipin antibody test was reported one time using code 86147, regardless of the number of classes evaluated, Wolfgang says. Code 86147 has been changed to read cardiolipin (phospholipid) antibody, each Ig class, so the code can be reported multiple times for multiple classes, Wolfgang adds. Also, 86146 has been added to report beta 2 Glycoprotein I antibody, each.

New Codes for New Procedures

Other than the new codes discussed above that help differentiate tests, several codes were added to CPT 2001 to describe new tests. These include:

80173 haloperidol
82373 carbohydrate deficient transferrin
83090 homocystine
84591 vitamin, not otherwise specified
85307 Activated Protein C (APC) resistance assay
86001 allergen specific IgG quantitative or semiquantitative, each allergen
86611 antibody; Bartonella
86666 antibody; Ehrlichia
86696 antibody; herpes simplex, type 2
86757 antibody; Rickettsia
88400 bilirubin, total, transcutaneous This code describes the monitoring of a patients bilirubin level by way of a monitor attached to the skin, Wolfgang explains. This code was placed in a new subsection called Transcutaneous Procedures, because this is an expanding area that may generate other new procedures and codes in the future. Infrared or optical sensors attached to the skin are being developed to measure blood gases, oxygen levels, etc.
89321 semen analysis, presence and/or motility of sperm.

This is the same description as HCPCS Level II code G0027. Report code 89300 for semen analysis including the Huhner test.

Clarifying Language

Many of the changes in the pathology/laboratory section of CPT 2001 involve addition of language to clarify how the codes are to be used, Castillo says. For example, the chemistry subsection specifies that the material for examination may be from any source, but in the 2001 edition, includes the clarification, unless otherwise specified in the code descriptor. This solves a possible contradiction in direction for codes that are substrate-specific.

Coding for drug testing is also clarified by changes in the introduction of the subsection, as well as changes in the wording of these codes:

80100 drug screen, qualitative; multiple drug classes chromatographic method, each procedure

80101 ... single drug class method (e.g., immunoassay, enzyme assay), each drug class.

The new language in the instructional notes for this section specifies that code 80100 describes chromatographic techniques used to identify multiple drug classes, and 80101 describes tests (such as immunoassays) for a single drug class. The changes further clarify that 80100 should be reported once for each combination of stationary and mobile phase. The new direction reads, for example, if detection of three drugs by chromatography requires one stationary phase with three mobile phases, use 80100 three times. However, if multiple drugs can be detected using a single analysis (e.g., one stationary phase with one mobile phase), use 80100 only once.

Similarly, coding for bacterial urinalysis is clarified by changes to the code and associated directions. Code 81007 was changed to read: urinalysis; bacteriuria screen, except by culture or dipstick. Notes following the code direct users: for culture, see 87086-87088; for dipstick, use 81000 or 81002.

Several other codes in CPT 2001 include new language to elucidate how they are to be used. These include:

82042 albumin; urine or other source, quantitative, each specimen
The descriptor is broadened to include substrates other than urine, and indicates that the code may be reported multiple times for multiple specimens.

82465 cholesterol, serum or whole blood, total
This code has been broadened to include whole blood as a test source because newer techniques now make this a common practice.

82787 gammaglobulin; immunoglobulin subclasses, (IgG1, 2, 3, or 4) each
The definition clarifies that the code is to be used once for each subclass.

83898 molecular diagnostics; amplification of patient nucleic acid (e.g., PCR, LCR), single primer pair, each primer pair
The change removes RT-PCR from the code.

86704 Hepatitis B core antibody (HBcAb)
The new descriptor substitutes the word total for IgG and IgM in the old code.

86708 Hepatitis A antibody (HAAb)
The new code substitutes the word total for IgG and IgM in the old code.

88180 flow cytometry; each cell surface, cytoplasmic or nuclear marker
This code has the added clarification: cytoplasmic nuclear marker

89125 fat stain, feces, urine or respiratory secretions
This code previously listed sputum, but now lists respiratory secretions instead.

To be well prepared to use the new codes correctly, Id recommend that you take your new and old CPT books and highlight the changes in the new version, Castillo says. Be sure to highlight changes in the narrative, not just the codes, including any directions cross referencing other procedures. Remember that changes to a parent code (the portion preceding the semicolon) mean changes to the children codes (indented codes following the parent). These will not be noted as revised in the CPT manual.

Note: Many of the CPT 2001 changes involve codes in the microbiology infectious agent detection subsection, containing codes 87260-87799. These changes will be discussed at length in the January issue of Pathology/Lab Coding Alert.