Pathology/Lab Coding Alert

Make sure you update your 'covered' ICD-9 codes

With new ICD-9-CM codes effective Oct. 1, your lab's "covered diagnosis" list can be a moving target. To get paid for tests covered under Medicare's National Coverage Determination (NCD) rules, you'll have to update your diagnosis code sets and make sure your physician clients do too.

Physician Assigns Ordering Diagnosis

Your lab stands to lose if you perform a test without an ICD-9 code on Medicare's covered diagnosis list. "But you have to use the ICD-9 code or narrative diagnosis supplied by the ordering physician - which can leave your lab in a bind if it's not covered," says Laurie Castillo, MA, CPC, CPC-H, CCS-P, owner of Castillo Consulting in Manassas, Va.

Use the summary chart to see NCD "covered diagnosis" code changes based on ICD-9 2005.

Tip: Make sure you have documentation that supports payable diagnoses for ordered lab tests. "Your lab can update requisition forms to reflect current diagnosis codes and ensure accurate physician ordering," Castillo says. If you don't have a payable diagnosis, you'll need to get a signed Advance Beneficiary Notification (ABN) and report the lab code with modifier -GA (Waiver of liability statement on file) so you can bill the patient for the test.

You Won't Get Paid for Truncated Codes

Whether you assign the ICD-9 code based on the physician's narrative diagnosis, or the physician assigns the ordering ICD-9, you must report the code to the highest degree of specificity. "That means no 'truncated codes' - using a general, three- or four-digit code instead of a more specific four- or five-digit code when one is available," Castillo says.

CMS made many of the NCD covered diagnoses changes shown in the chart to avoid truncated codes. Because ICD-9 2005 provides more specific codes for some conditions, you'll have to use the new five-digit code rather than the invalid four-digit code it replaces.

Watch out: Even if the medical record does not clearly define a condition, you should not use an incomplete, truncated code. Instead, use a complete four- or five-digit code that indicates that the diagnosis is "unspecified" (due to lack of complete documentation), or "other" if a more specific ICD-9 code is not available but the documentation states a specific diagnosis.

Example: A physician orders collagen crosslinks 82523 (Collagen crosslinks, any method) with a diagnosis of hyperparathyroidism. As of Oct. 1, Medicare will no longer pay for this test when ordered with 252.0 (Hyperparathyroidism) because the code is no longer valid under ICD-9 2005, and it is therefore not on the NCD payable diagnosis list. "Lacking more specific information, you'll have to report the test with the ordering diagnosis of 252.00 (Hyperparathyroidism, unspecified)," Castillo says.

You can't list 252.01 (Primary hyperparathyroidism) or 252.02 (Secondary hyperparathyroidism, non-renal) because the physician did not designate whether the condition is primary or secondary. Nor can you list 252.08 (Other hyperparathyroidism). "The word 'other' in the 252.08 code definition indicates a specifically designated type of hyperparathyroidism, not an unspecified type of hyperparathyroidism, which 252.00 describes," Castillo says.

Report Specific Drug-Use Codes

When physicians order lab tests to monitor patient response to medication, you'll have to use the most specific ICD-9 drug-use V code available, according to NCD changes. ICD-9 added two new long-term drug-use codes for 2005: V58.67 (Long-term [current] use of insulin) and V58.66 (Long-term [current] use of aspirin).

To demonstrate medical necessity for glucose or glycated hemoglobin ordered to monitor patients taking insulin, you should report new code V58.67, according to lab NCDs for those tests. You should list V58.67 for any patient who's taking insulin regularly, says Beth Fisher, medical systems specialist with the National Center for Health Statistics in Hyattsville, Md.

Don't overlook: Make sure the phrase "long-term" in the code's descriptor doesn't trip you up. Neither CMS nor NCHS has defined "long-term," Fisher says. Also, because the descriptor lists "current" beside the phrase, you can assign V58.67 for nearly "anybody who is using insulin," she adds. For instance, you could use the code for a gestational diabetes (648.8x) patient who's on insulin.

You'll also need to report a more specific long-term drug-use code for fecal occult blood tests for patients who regularly take aspirin, according to NCD changes. Before the change, you would have reported long-term aspirin use with V58.64 (Long-term [current] use of non-steroidal anti-inflammatories [NSAID]). But now that ICD-9 supplies V58.66, you should use the more specific code (see chart).