Pathology/Lab Coding Alert

NCD gives medical necessity with new codes

Expecting to get paid for prostate specific antigen based on urinary hesitancy or benign prostatic hypertrophy? Then you-d better update your records to include new ICD-9 codes and updated laboratory National Coverage Determination rules, both effective Oct. 1.

You-ll also need to know about new ICD-9 codes to report Pap smear and estrogen receptor test results--codes that could help show medical necessity for further procedures.

CMS Adds 600.00 to Covered List

After removing BPH in 2003 as a covered condition for diagnostic PSA, Medicare brings it back in the current NCD update. Change Request 5293, issued Sept. 7, adds 600.00 (Hypertrophy [benign] of prostate without urinary obstruction) to the list of covered ICD-9 codes. The change request also adds the following prostate hyperplasia ICD-9 codes, making diagnostic PSA payable for many 600 category codes:

- 600.10--Nodular prostate without urinary obstruction

- 600.11--Nodular prostate with urinary obstruction

- 600.21--Benign localized hyperplasia of prostate with urinary obstruction.

Example: A physician orders a PSA test for a patient diagnosed with BPH based on symptoms of urinary retention (788.20) and frequency (788.41).

Old way: The diagnostic test code is 84153 (Prostate specific antigen (PSA); total). In the past, you would have had to report a symptom code (788.20 or 788.41), which the ordering physician might not have provided to the lab.

New way: Now you can report the physician's BPH diagnosis (600.00). This change helps labs because physicians typically order the test with a diagnosis rather than the presenting symptoms that prompted the diagnosis.

Exception: Regardless of the reason for the test, when a diagnostic PSA test reveals an elevated antigen level, the diagnosis should reflect the results. CMS instructs coders to report 790.93 (Elevated prostate specific antigen) when the test shows elevated PSA.
 
If the physician provides a more specific diagnosis, however, choose an ICD-9 code that accurately reflects the patient's condition. For example, if the physician has established a diagnosis of prostate cancer, report the appropriate code, such as 185 (Malignant neoplasm of prostate) rather than elevated PSA (790.93).

Don't miss: Screening PSA tests--ordered with no signs or symptoms--are a different matter. You should report annual PSA screenings with G0103 (Prostate cancer screening; prostate specific antigen test [PSA], total), not 84153. Make sure tolink G0103 to V76.44 (Special screening for malignant neoplasms; other sites; prostate) as the reason for the test.

New Symptom Codes Indicate PSA, Urine Culture

The most recent ICD-9 update adds two new urinary symptom codes to improve coding specificity: 788.64 (Urinary hesitancy) and 788.65 (Straining on urination).

Coders will benefit from the addition of 788.64 and 788.65, two conditions that were previously not listed, says Susan Vogelberger, CPC, CPC-H, CMBS, owner and president of Healthcare Consulting & Coding Education LLC (HCCE) in Boardman, Ohio. You-ve been forced to report these symptoms with 788.9 (Other symptoms involving urinary system), but staring in October you-ll have more specific options.

The two new codes made it to the -covered codes list- for two lab NCDs: bacterial urine culture and PSA. The change is important because the PSA NCD did not include the general symptom code 788.9. That meant labs couldn't get paid for a PSA ordered for urinary hesitancy or straining.

Watch for New Pap Result Code

Labs have a new code to report Pap smear findings that point to a malignancy--795.06 (Papanicolaou smear of cervix with cytologic evidence of malignancy). -Use this code when the pathologist's interpretation of an abnormal Pap smear provides a strong indication of a cervical malignancy,- says Melanie Witt, RN, CPC-OGS, MA, an independent coding consultant in Guadalupita, N.M.

Warning: This code is not a cancer diagnosis, but it provides an indication for a biopsy to look for cancer. -A Pap only provides cytologic evidence--the pathologist needs histologic evidence to assign a cervical cancer diagnosis,- Witt says.

The new code is part of the abnormal Pap smear subcategory 795.0x (Abnormal Papanicolaou smear of cervix and cervical HPV). Other codes in the category align with the Bethesda nomenclature as follows:

- 795.01--Papanicolaou smear of cervix with atypical squamous cells of undetermined significance (ASC-US)

- 795.02--Papanicolaou smear of cervix with atypical squamous cells cannot exclude high-grade squamous intraepithelial lesion (ASC-H)

- 795.03--Papanicolaou smear of cervix with low-grade squamous intraepithelial lesion (LGSIL)

- 795.04--Papanicolaou smear of cervix with high-grade squamous intraepithelial lesion (HGSIL).

What to do: Although in the past you used 795.04 for cytologic evidence of carcinoma, the October ICD-9 update removes that wording from under the code. You should now use the new code, 795.06, to report those findings. The American College of Obstetricians and Gynecologists had requested a unique code for cytologic evidence of malignancy. -Code 795.06 implies a strong indication of cancer, and you would use it when the pathologist reports cytologic evidence of malignancy,- Witt says.

Exclusion: A revised note under 233.1 (Carcinoma in situ of cervix uteri) -excludes- 795.06, indicating that the two conditions are distinct. That means you should not use 795.06 to describe severe dysplasia of cervix or cervical intraepithelial neoplasia (CIN) III that the pathologist documents through histological examination.