Pathology/Lab Coding Alert

Four new and one revised code in CPT Codes 2001 have helped clarify coding for tumor markers, but getting paid for the tests can still be a problem. "The key to payment is understanding what diagnoses support medical necessity for the tests," says Kenneth Wolfgang, MT (ASCP), CPC, CPC-H, director of coding and analysis at National Health Systems Inc., a coding consultation company in Camp Hill, Pa. Laboratories should educate physicians about these coverage issues when they order the tests, and should ensure that an advance beneficiary notice (ABN) is on file for the service if it is ordered without a payable diagnosis.

"Prior to 2001, code 86316 described most immunoassays for tumor antigens, primarily in serum specimens," Wolfgang says. "However, some markers were covered by insurance based on their clinical usefulness for certain cancers, and others were not. Because 86316 did not provide a definitive account of which assay was carried out, it was difficult to establish medical necessity for the test."

With the addition of the four new codes, several specific tumor markers now have their own, and 86316 (immunoassay for tumor antigen; other antigen, quantitative [e.g., CA 50, 72-4, 549], each) was changed to represent any "other" antigen not specified in the new or existing codes. The new codes are 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) and 86304 (immunoassay for tumor antigen, quantitative; CA 125).
Medical Necessity
Medicare rules state that "Tests that are not reasonable and necessary for the diagnosis or treatment of an illness or injury are not covered. Failure to provide documentation of the medical necessity of tests may result in denial of claims." For many tests, the local Medicare carrier establishes the specific criteria for medical necessity in a local medical review policy (LMRP). But some tests are subject to a national Medicare coverage policy. Although many of the tumor markers are now under local rules, a national coverage policy has been proposed for the majority of these tests. The proposed rule was published in the March 10, 2000, Federal Register (pages 13082-13167), which can be downloaded from www.nara.gov/fedreg/index.html.

Some local carriers follow the proposed national rule while others do not, and still others have no written policy for the tests. "HCFA has reviewed comments for the proposed rule, and the final version is expected to be published in September 2001," says Suzzette Feliciano, reimbursement specialist for Polymedco, maker of several tumor- marker tests. After the final rule is published, carriers are expected to have one to two years to comply with the national coverage policy.

Note: HCFA has [...]