Pathology/Lab Coding Alert

Reimbursement for the acute hepatitis panel or individual hepatitis tests depends on assigning the proper procedural code(s) based on the laboratory methods used and antigen or antibody identified, as well as proper application of Medicare's coverage policies for medical necessity and frequency limits.
 
Although longstanding policy does not allow Medicare to cover tests performed in the absence of signs, symptoms or personal history of disease, hepatitis testing for asymptomatic patients may be covered for certain groups with risk of exposure to the illness, including certain patients undergoing transplants, transfusions or repeated dialysis.
 
Although CMS (formerly HCFA) has a proposed national coverage decision for the hepatitis panel, there is now no uniform policy for coverage of the panel or other hepatitis tests. "That means coders must be aware of a myriad of guidance for appropriate use of these tests, beginning with any local medical review policies (LMRPs) of their Medicare carrier or rules from third-party payers," says Stan Werner, MT (ASCP), administrative director and corporate compliance officer of Peterson Clinical Laboratory in Manhattan, Kan. 
Laboratory Methods, Nomenclature and Coverage Issues  
Whether testing for hepatitis A, B or C, analyses fall into three main categories: antibody tests by various methods, antigen tests by enzyme immunoassay (EIA), or infectious agent tests by nucleic acid probe technique. "Assigning the proper procedure code for a hepatitis test involves knowing both the method of testing and the viral antigen or antibody identified," Werner says. "But the key to reimbursement for the tests is documentation of patient status that supports medical necessity for diagnosis or treatment of disease, not for screening."
 
Although specific coverage policies for individual hepatitis tests will vary by carrier or third-party payer, several diagnoses indicate medical necessity for hepatitis testing. These include patients diagnosed with HIV (042), viral hepatitis (070.0-070.9), liver disorders (570-573.9), jaundice (not of newborn, 782.4 ), repeat dialysis patients (585-586 and V45.1) and liver transplant patients (996.82 and V72.85).
 
"Despite the fact that LMRPs and third-party payer rules may vary for these tests, a general understanding of what each assay reveals about the patient's hepatitis infection or immunity status will help coders know when an ordered test is indicated," says Laurie Castillo, MA, CPC, CPC-H, CCS-P, a member of the National Advisory Board of the American Academy of Professional Coders. For example, it would be improper to run the hepatitis B test for infectivity on a patient who has not even been diagnosed with the disease.
 
"Although the treating physician orders the tests, Medicare's compliance guide charges laboratories with ensuring documentation of medical necessity for the tests they run," Castillo says. "Of course labs cannot tell physicians what tests to order, or which diagnosis codes to use, but they must educate physicians about [...]