Pathology/Lab Coding Alert

To use or not to use the new codes: that is the question.

As with last year’s new molecular pathology codes, you probably won’t be able to use the eight new CPT^® 2013 codes for multi-analyte assays with algorithmic analyses (MAAAs).

That’s because CMS states, "we will not recognize these nine MAAA codes for CY 2013," and places the codes in the physician fee schedule with a procedure status indicator of I (Not valid for Medicare purposes. Medicare uses another code for the reporting and payment of these services).

Find out: So what are these tests, and how does coding instruction for these services vary depending on whether you’re consulting CPT^® or CMS? Read on to let the experts help you sort it out.

Recognize MAAA Tests

CPT^® 2013 introduces a new section for MAAAs, which are "procedures that utilize multiple results derived from assays of various types … as well as other patient information (if used)" to perform algorithmic analysis and report findings as a numeric score or probability. The assays involved in the MAAA could include molecular pathology tests, fluorescent in situ hybridization (FISH), as well as other procedures such as protein, polypeptide, lipid and carbohydrate tests.

MAAAs are "tests developed to answer particular clinical questions" that analyte results alone would not necessarily answer for treating physicians, according to Paul Radensky, M.D., representing McDermott Will & Emery at the annual CMS public meeting for pricing 2013 lab codes on the Clinical Laboratory Fee Schedule (CLFS).

There’s more: MAAAs are not just a panel of tests. Instead, the algorithm represents a substantial component of the test, according to Peter Kazon, speaking on behalf of American Clinical Laboratory Association (ACLA) at the CLFS public meeting.

Be specific: MAAAs are generally uniquely available through a single lab or vendor, according to Mark S. Synovec, M.D., College of American Pathologists, AMA CPT^® Editorial Panel member at the AMA’s annual CPT^® and RBRVS Symposium, held Nov. 14-16 in Chicago.

See a complete list of the new CPT^® 2013 Category I MAAA codes in "MAAA Line-up: Get Familiar With 9 New Algorithm Codes" on page 11.

That’s not all: Because MAAAs are typically unique to a single clinical lab or manufacturer, and because there’s ongoing development of new MAAAs, CPT^® 2013 created Appendix O. The appendix lists the proprietary name and manufacturer with the associated code and descriptor.

Keep up with administrative codes: You’ll find the eight new CPT^® Category I MAAA codes in appendix O, but you’ll also see different MAAAs listed with an "administrative code." These are tests that have not been assigned a Category I code. The AMA may add new administrative MAAA codes on the CPT^® Website in March, June, and November, corresponding to the CPT^® Editorial Panel actions, explained Mark S. Synovec, M.D., College of American Pathologists, AMA CPT^® Editorial Panel member at the AMA’s annual CPT^® and RBRVS Symposium, held Nov. 14-16 in Chicago.

What’s Included

Each MAAA code, whether Category I or an administrative code, "encompasses all analytical services required for the algorithmic analysis … in addition to the algorithmic analysis itself." according to CPT^® instruction.

That means the codes include any or all of the following services, if performed:

Chemistry assays

Biochemical assays

FISH

Patient data

Any of the following steps for molecular analyses:

o Cell lysis

o Nucleic acid stabilization

o Extraction

o Digestion

o Amplification

o Hybridization and detection

Algorithmic analysis

Report

Extra services: If the MAAA requires any tissue preparation prior to cell lysis, you can separately code that procedure. For instance, you might perform and report one of the following services before performing a molecular analysis that is part of a MAAA test:

Microdissection (88380-88381, Microdissection [i.e., sample preparation of microscopically identified target] …)

Macro tissue prep (88387-+88388, Macroscopic examination, dissection, and preparation of tissue for non-microscopic analytical studies [e.g., nucleic acid-based molecular studies]…)

Archived specimen selection (88363, Examination and selection of retrieved archival [i.e., previously diagnosed] tissue[s] for molecular analysis [e.g., KRAS mutational analysis])

Caution: Make sure you abide by restrictions for reporting any of these services together, such as a Correct Coding Initiative (CCI) edit for 88380 and 88381 with 88363. Select only the most extensive procedure your lab performs.

CPT® Says Bill This Way

The CPT^® 2013 instruction for MAAAs indicate that you should select the single, specific Category I code or administrative code from Appendix O that describes the analysis. As explained in the prior section, "What’s Included," the code describes all the assays, molecular or otherwise, and the algorithm analysis and report.

Even if the report lists the results of the individual component procedures, "these assays are not reported separately using additional codes," according to CPT^® instruction. In other words, don’t report a MAAA code plus the code for the underlying tests.

For example: The lab performs the ROMA (Risk of Ovarian Malignancy Algorithm) assessment, which combines the results of an HE4 and a CA 125 test, along with menopausal status, into a numeric score. This MAAA helps to identify patients presenting with adnexal mass as high or low likelihood for finding malignancy with surgery. For this service, report 81500 (Oncology (ovarian), biochemical assays of two proteins (CA-125 and HE4), utilizing serum, with menopausal status, algorithm reported as a risk score), not 81500 plus 86304 (Immunoassay for tumor antigen, quantitative; CA 125) and 86305 (Human epididymis protein 4 [HE4]), according to CPT^® instruction.

No specific code? Report the unlisted MAAA code (81599) only if CPT^® doesn’t provide either a Category I or administrative code for the MAAA.

CMS Says Bill That Way

If you’re billing Medicare for a MAAA procedure, forget everything you just read. CMS "does not recommend separately pricing the MAAA codes," according to the CLFS final payment determination. That means you won’t get paid if you bill a code from the range 81500-81599 to a Medicare payer.

Instead, CMS intends for labs to use "other codes for payment of the underlying clinical laboratory tests on which the MAAA is done."

Prior example: For the ROMA procedure described in the earlier example, you should bill Medicare payers using 86304 (CA 125) and 86305 (HE4).

Here’s why: CMS states that the agency "does not recognize algorithmically derived rate or result as a clinical laboratory test."