Pathology/Lab Coding Alert

HCFA has temporarily suspended many of the edits in version 6.3 of the national Correct Coding Initiative (CCI). These edits bundled 66 evaluation and management (E/M) services to more than 50 pathology and laboratory procedural codes. The suspension, issued Jan. 26, affects many of the 3,500 edits and is retroactive to Oct. 30, 2000, the date the 6.3 edits were issued.

Most significant about the 6.3 edits was the bundling of E/M services with diagnostic procedures a decision that took many physicians and coders by surprise, says Barbara Cobuzzi, CPC, CHBME, president of Cash Flow Solutions Inc. in Lakewood, N.J. The changes were not adequately publicized and placed a financial burden on those who were suddenly receiving denials for previously covered procedures, she says. Claims denied under the 6.3 edits should be resubmitted for adjustment with modifier -25 (significant, separately identifiable evaluation and management service by the same physician on same day of the procedure or other service) appended to the E/M service if the service meets the separate and significant criteria. In deciding which claims may qualify, physicians and coders should look to the explanation of medical benefits on the insurance form. It will indicate that the claim was denied or reduced because either the service was not significant or separately identifiable or payment was included in another service received on the same day.

Impact on Pathology Coding

The pathology edit pairs suspended by HCFA include bundling of E/M services with evocative/suppression and other laboratory tests, certain anatomic pathology codes and some blood banking and transfusion medicine codes.

The primary problem with the bundling arises when E/M services and a diagnostic lab or pathology service are reported by the same facility for the same patient on the same day, says Laurie Castillo, MA, CPC, CPC-H, CCS-P, member of the National Advisory Board of the American Academy of Professional Coders. For example, if a hospital emergency department and hospital laboratory billed for the E/M and lab service under the CCI version 6.3 edits , they would have had to use modifier -25 for both services to be reimbursed. Similarly, if a patient is seen at a hospital-owned clinic and has lab work done by the hospital lab, the services would have been subject to these edits, Castillo says. Unless or until these edits are put back in place, hospitals wont need to use modifier -25 in these cases.

However, the suspension of CCI version 6.3 will not impact coding for many independent pathology practices, says R.M. Stainton Jr., MD, president of Doctors Anatomic Pathology Services, an independent pathology laboratory in Jonesboro, Ark. Many of these services do not normally entail the pathologists oversight of the patient, Stainton says. When a pathologist in our practice conducts a fine needle aspiration (88170-88171), bone marrow aspiration (85095), biopsy (85102) or consultation during surgery (88329-88332), the referring physician is still the individual responsible for the patient evaluation and management. In these cases, we dont use the E/M codes because we dont provide that service.

Hematologists, Blood Bank, Transplant Physicians

Unlike pathologists providing laboratory or anatomic pathology services, those serving as hematologists, blood bank physicians and transplant physicians may be involved in evaluation and management of the patient in conjunction with some of the services bundled with E/M codes in CCI version 6.3.

We are very happy to see the edits related to transplant services suspended, says Nancy Cothern, business manager of Baptist Regional Cancer Institute in Jacksonville, Fla. The transplant physician must be involved in patient care every step of the way, and certainly provides E/M services in conjunction with some of the procedures that were affected by these edits.

For example, an oncologist treating a patient with acute leukemia (208.00) may request a consultation with a transplant physician regarding a stem-cell transplant. The initial outpatient encounter is reported using an E/M consultation code (99241-99245), with the code selected based on the nature of the history, examination and medical decision-making, as well as the time involved in the exam. Consultation codes are used only when another physician (such as the patients oncologist) requested the consult, and the consulting pathologist renders a medical judgment and writes a report.

If the patient is slated for a stem-cell transplant following the initial consultation, the care of the patient is transferred to the transplant physician until the entire treatment is completed, Cothern says. Because of this arrangement, the transplant physician initiates subsequent visits and reports office visit codes for established patients (99211-99215), he says.

The patient will usually return for two or three sessions of cytapheresis. The code for stem-cell apheresis is 38231 (blood-derived peripheral stem cell harvesting for transplantation, per collection).

In addition to the apheresis service, Our transplant physicians document the E/M services that they provide to the patient during the stem cell-collection, Cothern says. Although we always document all services provided, reimbursement depends on the type of insurance, she says. Medicare has a long-standing CCI edit for apheresis (38231) and E/M codes 99211-99215. This edit is not a part of the suspended version 6.3 edits.

Following high-dose chemotherapy to destroy the cancer cells, the patient returns for the stem-cell transplant (38241, or 38240 if the cells were derived from a donor). Separate E/M services are typically provided by the transplant physician during these procedures, Cothern says. Codes 38240 and 38241 were bundled with the E/M services in the version 6.3 edits.

Other transfusion medicine services that may be provided on the same day as the apheresis or transplantation were also part of the E/M bundling in CCI version 6.3. These include 86890 (autologous blood or component, collection processing and storage; predeposited) and 86950 (leukocyte transfusion).

Blood bank physicians may also be impacted by the suspended version 6.3 edits. Three blood bank physician codes were bundled with E/M codes under version 6.3:

86077 blood bank physician services; difficult cross match and/or evaluation of irregular antibody(s), interpretation and written report;

86078 ... investigation of transfusion reaction including suspicion of transmissible disease, interpretation and written report; and

86079 ... authorization for deviation from standard blood banking procedures (e.g., use of outdated blood, transfusion of Rh incompatible units), with written report.

According to Catherine Saporito, MT (ASCP), SBB, blood bank manager at University of Illinois Hospital in Chicago, these services do not routinely require the blood bank physician to be involved with patient evaluation and management. While evaluating a difficult cross match or transfusion reaction, the patient normally remains under the care of the attending physician, she says.

However, in other settings, hematologists may provide patient E/M while furnishing some of these transfusion and blood bank services. This might include patient examination, writing progress notes and giving clinical orders regarding such issues as fluid replacement. With the suspension of the new E/M edits in CCI version 6.3, modifier -25 is no longer necessary to ensure reimbursement when these services are provided together.

Outlook for Suspended CCI Edits

Before reinstating any of the suspended edits, HCFA will develop a program that will include carrier guidance and education, and directions to publish edit information in carrier bulletins. The agency will also look at clarifying the criteria for a significant and separate service and will consider implementing national policy allowing one diagnosis code to be used for an E/M service and procedure for the same patient on the same day.

HCFA has pledged to work with the AMA and other medical societies to continue educational efforts on the use of appending modifier -25 to E/M services when billed with pathology procedures performed on the same day. Modifier -25 is appropriate when the work of the E/M procedure is significant and separate from work that is inherent in the pathology procedures, HCFA states. This is correct coding and should be practiced regardless of any edits HCFA may implement in the future.

HCFA is reviewing the edits, and a number of them may be reimplemented no earlier than July 1, 2001. The suspension does not affect E/M services edits that were implemented before Oct. 30, 2000.