Pathology/Lab Coding Alert

AMA reinstates 'per-plate' coding instruction

You just adjusted your stool culture coding to accommodate CPT 2004 changes, and now the AMA errata send you back to the old way. Once again, you can bill separately for each additional stool culture plate using CPT 87046 (Culture, bacterial; stool, aerobic, additional pathogens, isolation and presumptive identification of isolates, each plate).
 
After removing "per plate" from the code definition, the AMA returned those words to 87046 in the errata posted to their Web site at http://www.ama-assn.org/ama/pub/article/3896-8059.html. Based on the errata, our experts have revised some advice offered in "Don't Code Extra Cultures for Stool and Blood" and "Think You'll See $13.52 for Each Stool Isolate?" in the May 2004 issue of Pathology/Lab Coding Alert .

Returning "per plate" to the code definition allows labs to capture all additional stool cultures. "Without 'per plate' in the definition, we could not bill when our lab tested for more than one additional enteric pathogen -- returning 'per plate' to the definition allows us to account for each additional plate we inoculate to identify additional pathogens," says Vickie Baselski, PhD, department of pathology, University of Tennessee Health Science Center in Memphis.

Enjoy 4 Times the Pay in 2004

Because the service described by 87046 remains unchanged from the 2003 definition, your lab should get the full benefit of Medicare's national limit payment increase for the code, from $3.36 in 2003 to $13.52 in 2004.

When the lab performs a stool culture for Salmonella/Shigella, report 87045 (Culture, bacterial; stool, aerobic, with isolation and preliminary examination [e.g., KIA, LIA], Salmonella and Shigella species). If the lab performs additional tests for other enteric pathogens, you should also report 87046 for each plate.

Example: The physician orders a routine stool culture, which includes Salmonella/Shigella and Campylobacter. The physician also orders additional tests for Yersinia, and E. coli 0157. "Our laboratory includes Salmonella, Shigella and Campylobacter as a routine stool culture, based on studies of pathogen prevalence, but also allows the physician to order analyte-specific tests for Yersinia, Vibrio, and enterohemorragic E. coli," Baselski says. 

Old way: Before the AMA issued the errata, our experts advised you to report this example with one unit of 87045 for the Salmonella/Shigella, and one unit of 87046 for the combined Campylobacter, Yersinia and E. coli 0157 testing. "That meant we had to bill 87045 and 87046 for a routine stool culture that included Salmonella, Shigella and Campylobacter, and we could not bill for the additional plates for Yersinia and E. coli," Baselski says.

New way: Now you should report this example using 87045 for the Salmonella/Shigella culture and three units of 87046. "Because the AMA reinstated 'per plate' in the code definition, you should report 87046 for each additional stool culture plate," says Lisa Miller, MS, policy representative of the College of American Pathologists in Washington, D.C.

"Now we report 87045 and 87046 for our routine stool culture, and one unit of 87046 for each additional pathogen plate specifically ordered by the physician," Baselski says.

You should report the three units of additional stool culture plates as 87046 x 3, or list each additional unit of 87046 with modifier -59 (Distinct procedural service) or modifier -91 (Repeat clinical diagnostic laboratory test). Follow your carrier's requirements regarding which reporting method to use.

Medicare Pricing Not Linked to Code Change

If Medicare raised the 87046 payment rate in 2004 to accommodate the removal of "per plate" from the CPT code definition, some coders have raised ethical concerns about billing 87046 per plate.

"But CMS announced its intention to increase payment for 87046 based on other remarks before the AMA implemented CPT 2004," Miller says. (See editor's note below for reference to this announcement.) Baselski agrees that the fee schedule increase was not linked to the CPT code change -- many groups have challenged CMS' original 2001 mapping of 87046 to 25 percent of 87045.

AMA Removed 'Per Plate' in Error

The AMA did not remove "per plate" from 87046 by way of a panel action, according to Tracy Gordy, MD, chair of the CPT Editorial Panel. The phrase was removed erroneously through the editorial process, and the errata simply replaced "per plate," he says.

You Can Bill for Negative Cultures

Can you report multiple units of 87046 even if all or some of the plates are negative? Yes, according to Baselski. "CPT coding represents the work the lab performs, not whether the lab recovers a pathogen," she says.

"Similarly, if the lab performs additional identification such as biochemical tests for an isolate that turns out to be non-pathogenic, you should still report the service as 87077 [... aerobic isolate, additional methods required for definitive identification, each isolate]," Baselski says.

Editor's note: Medicare announced its intention to change pricing for 87046 on Nov. 7, 2003, in its 2004 "Annual Summary of Changes for Clinical Laboratory Fee Schedule." The notice states that based on comments, CMS revised mappings for 87046 and eight other codes, none of which were modified in CPT 2004. You can access change notice 2959 on the Internet at http://www.cms.hhs.gov/manuals/pm_trans/R20OTN.pdf.