Pathology/Lab Coding Alert

Payment rates are just the tip of the iceberg in the 2003 Physician Fee Schedule. Looming beneath the surface are payment and coding policies that labs must heed to receive proper reimbursement.

With direction about how to use specific CPT Codes and the addition of several new HCPCS Level II codes , you can't afford to ignore Medicare's policy instructions published in the Dec. 31, 2002, Federal Register. Coding for fine needle aspiration (FNA) surgical procedures, stem-cell transplants, and home prothrombin time (PT), among others, requires knowledge of the new CMS rules.

CMS Writes Its Own Stem-Cell Codes

Although CPT 2003 provides sweeping changes to stem-cell transplant coding (see "Stem-Cell Codes Add Up to Accurate Reimbursement" in the January 2003 Pathology Lab Coding Alert), Medicare will not recognize many of the new codes.

Medicare will not pay for the new management code 38204 (Management of recipient hematopoietic progenitor cell donor search and cell acquisition), giving it a "B" status indicator in the fee schedule. "This code represents a whole new way of thinking about physician work," says Samuel Silver, MD, PhD, medical director of the Cancer Center Network at the university of Michigan and representative of the American Society of Hematology on the AMACPTAdvisory Committee.

Finding an unrelated donor requires a lot of work by the physician, yet it doesn't occur face-to-face with the patient, as do most procedures, Silver says. CMS provides no substitute code for this service because it believes that the physician management is already incorporated in the other transplant service codes (for example, 38205-38206 and 38240-38242).

Similarly, CMS rejects new codes 38207 (Transplant preparation of hematopoietic progenitor cells; cryopreser-vation and storage), 38208 ( thawing of previously frozen harvest) and 38209 ( washing of harvest) as an "unbundling of existing codes 88240 (Cryopreservation, freezing and storage of cells, each cell line) and 88241 (Thawing and expansion of frozen cells, each aliquot). Because CPT2003 directs coders to use 88240 and 88241 only for diagnostic services beginning Jan. 1, CMS created two HCPCS Level II codes to report these procedures when carried out for Medicare beneficiaries receiving stem-cell transplant services. They are G0265 (Cryopreser-vation, freezing and storage of cells for therapeutic use, each cell line) and G0266 (Thawing and expansion of frozen cells for therapeutic use, each aliquot).

Medicare also rejects other new codes in the 38207 family that describe specific cell depletion or concentration (38210-38215). Because CPT2003 deleted the single code that these six codes replaced (86915, Bone marrow or peripheral stem cell harvest, modification or treatment to eliminate cell type[s] [e.g., T-cells, metastatic carcinoma]), CMS also provides a new G code for this service G0267, which has the same definition as 86915.

Home Prothrombin Time Takes New G Codes

Special provisions of the 2003 fee schedule provide home prothrombin time (PT) coverage and coding instructions. "PTis often used to monitor patients taking the drug warfarin (Coumadin)," says Barb Miller, MT(ASCP) SH, clinical lab specialist with Nebraska Health System in Omaha. The PTtest results may be expressed as an international normalized ration (INR), which normalizes test results to a reference thromboplastin coagulation time.

For patients with mechanical heart valves who are on anticoagulation therapy and meet certain criteria, Medicare now covers home PT/INR testing using kits that provide for repeat measurements. Do not report the home PT test as 85610 (Prothrombin time). Rather, use one of the new HCPCS Level II codes that Medicare provided to describe the service.

For the first home-testing encounter, report G0248 (Demonstration, at initial use, of home INR monitoring for patient with mechanical heart valve[s] who meets Medicare coverage criteria, under the direction of a physician; includes: demonstrating use and care of the INR monitor, obtaining at least one blood sample, provision of instructions for reporting home INR test results, and documentation of patient ability to perform testing). Report the PT/INR monitoring, coded per four tests, as G0249 (Provision of test materials and equipment for home INR monitoring to patient with mechanical heart valve[s] who meets Medicare coverage criteria; includes provision of materials for use in the home and reporting of test results to physician; per four tests). Report G0250 (Physician review, interpretation and patient management of home INR testing for a patient with mechanical heart valve[s] who meets other coverage criteria; per four tests [does not require face-to-face service]) separately when the physician evaluates the test results.

The Wait Is on for Expanded FOBT Coverage

For now, only guaiac testing passes muster with Medicare for colorectal screening. Although claiming in the 2003 fee schedule preamble that it is expanding the definition of screening fecal-occult blood tests (FOBT), CMS stated that the change would come through the national coverage determination (NCD) process. Until that time, continue to report annual guaiac FOBT colorectal cancer screening for patients 50 years of age or older with G0107 (Colorectal cancer screening; fecal-occult blood test, 1-3 simultaneous determinations).

CMS Proclaims FNA Global Only

FNA procurement codes 10021 (Fine needle aspiration; without imaging guidance) and 10022 ( with imaging guidance) lost their technical and professional component designations in the 2003 fee schedule. You should no longer bill these services using modifiers -26 (Professional component) and -TC (Technical component).

"Billing FNAas a global service should not be an issue because it is like any other surgical procedure that incorporates the technical component into the Ambulatory Payment Classifications (APC) rate," says Cindy Parman, CPC, CPC-H, principal with Coding Strategies Inc. in Powder Springs, Ga. "In fact, removing the -TC and -26 modifiers should probably have occurred last year when the procedure codes for FNAs were moved from the pathology section (88170 and 88171) to the surgery section (10021 and 10022)."

The good news is that FNAprocurement is a winner in the 2003 fee schedule, more than doubling the payment rate compared to the global service last year (see "Medicare Payment Change How Will You Fare?" in the February 2003 Pathology/Lab Coding Alert). "It may be that moving the FNAprocedure codes to the surgery section led to more accurate reporting last year, giving us better data that is reflected in the payment rate this year," Parman says.

Pathologists should continue to bill the FNAsmear evaluation using the appropriate code: 88172 (Cytopathology, evaluation of fine needle aspirate; immediate cytohistologic study to determine adequacy of specimen[s]) and/or 88173 ( interpretation and report).