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Pathology/Lab Coding Alert

Don't Miss Payment for New Electrophoresis Codes

Published on Wed Jun 08, 2005

Look for pro-fee denials with non-serum sources

You've always billed for your pathologists' protein and immunofixation electrophoresis interpretations, but suddenly you're getting denied - what gives? The answer is an administrative snafu with CMS payment for CPT 84166 and 86335.

Be on the lookout for claim denials when you bill the professional fee for these codes using modifier -26 (Professional component). Then use the documentation our experts provide to file an appeal with your carrier.

CPT Splits Electrophoresis Codes by Specimen Type

You used to report protein and immunofixation electrophoresis using just two codes regardless of the source: 84165 (Protein; electrophoretic fractionation and quantitation) and 86334 (Immunofixation electrophoresis). But CPT 2005 changed this coding by revising 84165 and 86334 and adding new codes 84166 and 86335. CPT revised the existing codes to specify that the sample source is serum:

  •  84165 - Protein; electrophoretic fractionation and quantitation, serum

  •  86334 - Immunofixation electrophoresis; serum.

    CPT also added two new codes for the same test when the lab performs it on fluid sources other than serum:

  •  84166 - Protein; electrophoretic fractionation and quantitation, other fluids with concentration (e.g., urine, CSF)
  •  86335 - Immunofixation electrophoresis; other fluids with concentration (e.g., urine, CSF).

    The new codes are the source of some Medicare denials when you bill the professional fee. "We were having some problems with reimbursement for codes 84166 and 86335 billed with modifier -26, but we spoke with our carrier, and it has corrected the situation," says Beverly Bloedow, coding resource specialist for Hospital Pathology Associates in Minneapolis.

    Law Limits Clinical Lab Interpretation

    The problem stems from Medicare's list of covered clinical laboratory interpretive services. "The Medicare Claims Processing Manual (CMS IOM Pub. 100-4), Chapter 12, Section 60E, includes a table of 18 clinical laboratory tests that a pathologist may interpret and report with modifier -26 under conditions that meet the coverage criteria," says Dennis Padget, MBA, CPA, FHFMA, president of DLPadget Enterprises Inc., a pathology business practices publishing company in Simpsonville, Ky. Although the instructions provide that "CMS periodically reviews this list and adds or deletes clinical laboratory codes as warranted," CMS has not updated the list to accommodate the electrophoresis code changes. That's apparently why some carriers won't pay the pathologist's interpretation service.

    Pathologists regularly interpret and report protein and immunofixation electrophoresis tests on serum, urine, cerebral spinal fluid (CSF) and other human body fluids. "Since 1992, Medicare Part B contractors have paid for these professional services, irrespective of the type of body fluid that is the specimen," Padget says. "Section 60E nowhere suggests that coverage for code 84165-26 and/or 86334-26 may depend on the type of specimen, nor should it," he says.

    But now you have to report non-serum protein and immunofixation electrophoresis with 84166 and 86335, which Medicare has not yet added to the list of covered clinical lab interpretive services in MCPM. "Because both 84166 and 86335 appear in Addendum B of the 2005 Medicare Physician Fee Schedule with the -26 modifier and a positive RVU [relative value unit], it appears that Medicare's failure to update the list in the MCPM is an oversight," Padget says.

    Use 3-Step Test to Find Legitimate Pro-Fee Appeals

    If your carrier denies claims for 84166-26 and 86335-26, you should evaluate the denials to see if you have legitimate cause for appeal. Ask three questions to determine if you should appeal the claim:

    1. Does your claim meet the requirements for professional interpretation of a clinical lab test result as outlined in MCPM, Chapter 12, Section 60E? The instructions require the following to justify the pro fee: 

  • Request: The attending physician must ask for an interpretation, but for the specific tests listed in Section 60E, the request can be by a hospital's medical staff standing order;
     
  • Abnormal/normal result: The result (normal or abnormal) doesn't matter for the specific tests in this category;
     
  • Opinion: The pathologist must exercise medical judgment regarding the test result; and
     
  • Report: The pathologist must issue a written report.

    You don't have a valid claim if you miss even one of these criteria. If you meet them all, evaluate the other questions to see if you should appeal.

    2. What is the reason for denial? If the carrier's explanation of Medicare benefits (EOMB) states that you can't bill these codes with modifier -26, you probably have cause for appeal because that's just not true, according to the 2005 Physician Fee Schedule.

    3. Does the carrier continue to pay 84165-26 and 86334-26 claims for serum specimens while denying the same pro-fees for "other fluid" specimens? If so, you're probably caught in the administrative snafu and should appeal the claim.

    Do this: To file an appeal, marshal your resources to document the claim. Use the following references and links to access authoritative documents that you can cite to support your claim: 

  • Medicare 2005 Physician Fee Schedule, which includes 84166 and 86335 with modifier -26: http://www.cms.hhs.gov/physicians/pfs/default.asp 
     
  • Medicare Claims Processing Manual (CMS IOM Pub. 100-4). Chapter 12, Section 60E, which shows the criteria for pathologists' professional interpretation of clinical laboratory tests: http://www.cms.hhs.gov/manuals/104_claims/clm104c12.pdf 
     
  • CPT 2005 Changes, An Insider's View, which states that the rationale for 84166 and 86335 is to provide "a more specific and accurate description of ... specimen sources for protein and immunofixation electrophoresis procedures." 

    Also read "Improve 'Second Chance' for Claims Denials" later in this issue for more information about filing appeals.

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