Pathology/Lab Coding Alert
Got Medical Necessity? Look for New ICD-9 Codes in Lab NCDs and LMRPs
Don't get caught with old diagnosis codes that won't get your lab claims paid. ICD-9 2004 code changes, which go into effect Oct. 1, are finding their way into your "covered diagnosis codes" lists for laboratory national coverage determinations (NCDs) and local medical review policies (LMRPs). Many of the approximately 100 new, 20 revised and 30 invalid ICD-9 codes will provide clinical lab coders with more specific diagnosis codes. "The latest version of ICD-9 invalidates some four-digit codes and adds more specific five-digit codes to take their place," says William Dettwyler, MT-AMT, coding analyst for Health Systems Concepts, a laboratory coding and compliance consulting firm in Longwood, Fla. You can find the list of code additions, changes and deletions in program memorandum AB-03-091, which is available on the CMS Web site at http://www.cms.gov/manuals/pm_trans/AB03091.pdf. Report Ordering Diagnosis Labs can't assign the diagnosis code for a clinical lab test; they can only report what the ordering physician designates as the reason for the test. "But labs need to know which diagnosis codes indicate medical necessity for tests and ensure that their physician clients either use those codes or supply a signed advance beneficiary notice (ABN)," Dettwyler says. "With an ABN, the lab can bill the patient for a noncovered test." Lab NCDs Update Covered ICD-9 Codes CMS announced NCD coverage changes based on 2004 ICD-9 codes. You can access the program memorandum AB-03-104 on the CMS Web site at http://www.cms.gov/manuals/pm_trans/AB03104.pdf. Beginning Oct. 1, NCD software will edit for the new codes, although CMS will not remove the invalid codes until the end of the 90-day grace period on Jan. 1, 2004. The table shows new ICD-9 codes and the associated NCDs that list the codes as "covered diagnoses." Most of the added codes are five-digit subclassifications that replace invalid four-digit codes. But ICD-9 added some new five-digit codes in the table to existing four-digit subcategories. Watch LMRPs for Updated ICD-9 Codes Because carriers vary regarding when and how they incorporate diagnosis code changes into LMRPs, you should be on the lookout for specific changes that impact your lab. Any updates should be easy to find, especially for new five-digit codes that replace invalid four-digit codes. "If you know which of your LMRPs utilized an invalid four-digit code, you can expect your carrier or fiscal intermediary [FI] to modify that policy to incorporate the new five-digit codes," says Larry Small, MS, MT (ASCP), director, compliance and billing services for PCS Laboratory Service Group in Ann Arbor, Mich. For example, many LMRPs for metabolic panels (80048, Basic metabolic panel; and 80053, Comprehensive metabolic panel) now list invalid codes 255.1 (Hyperal-dosteronism) and 277.8 (Other specified disorders of metabolism) as covered diagnoses. Watch for LMRP changes to incorporate any or all of the following new five-digit ICD-9 codes that replace 255.1 and 277.8:
Similarly, some LMRPs for blood counts (such as 85025, Blood count; complete [CBC], automated [Hgb, Hct, RBC, WBC and platelet count] and automated differential WBC count) now list 289.8 (Other specified diseases of blood and blood-forming organs) as a covered diagnosis. You might expect an update to those policies to include the following new five-digit codes: "Be sure that you don't begin using these new codes until your carrier or FI implements the changes," Small says.
"You should utilize the grace period until Jan.1 to coordinate with your local Medicare agency for making the change." You should inform your physician clients of any updated ICD-9 code requirements, because they must provide you with more precise documentation to accommodate the new codes. 
Pathology/Lab Coding Alert
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