Pathology/Lab Coding Alert

Uniform coverage rules for clinical diagnostic lab tests will provide welcome consistency as new national policies curtail the discretion of individual Medicare carriers to establish conflicting local medical review policies (LMRPs). Twenty-three new national coverage policies for clinical diagnostic laboratory tests are scheduled to go into effect on Nov. 25, 2002.

"The good news is that standardization of coverage should make it easier for laboratories that provide services under the authority of multiple carriers," claims Stan Werner, MT (ASCP), administrative director of Peterson Clinical Laboratory in Manhattan, Kan. "The bad news labs are going to have to review their current policies and make systematic changes to accommodate any differences."

The "Final Rule for Coverage and Administrative Policies for Clinical Diagnostic Laboratory Services," published in the Nov. 23, 2001, Federal Register, contains the text of the 23 new coverage policies and other laboratory administrative guidelines. Locate this resource on the Internet at www.access.gpo.gov/su_docs/fedreg/ a011123c.html, under CMS.

"The national coverage decisions and the administrative elements of the Final Rule should prove beneficial for clinical laboratories," says E. Eugene Baillie, MD, FASCP, president-elect of the American Society for Clinical Pathology (ASCP) and pathologist with Anderson Area Medical Center in Anderson, S.C. "Having all the information standardized and centralized in the Final Rule provides a great resource for anyone dealing with laboratory coverage policy issues."

Learn the Format of National Coverage Policies

"The Final Rule presents the 23 national coverage decisions in a clear and consistent format, making it easy for lab personnel to understand," says Laurie Castillo, MA, CPC, CPC-H, CCS-P, member of the national advisory board of the American Academy of Professional Coders (AAPC) and president of Physician Coding and Compliance Consulting in Manassas, Va. Following the name, narrative description, and list of CPT codes, the Final Rule describes the clinical indications and any frequency limitations for Medicare coverage, specifically linking procedure codes to diagnosis codes.

"By linking the ICD-9 and CPT codes, it should be clear when a test is covered by Medicare," Werner says. "This should minimize the confusion we currently have, where individual carriers often have different opinions on coverage issues."

Each clinical diagnostic laboratory test is linked to ICD-9 codes that are covered for the specific procedure, as well as ICD9 Codes for which coverage would be denied. A third category of ICD-9 codes indicates diagnoses that "do not support medical necessity." These diagnoses would not generally be covered but might be reimbursable when supported by extra documentation. For most policies, this category includes any codes not listed as "covered" or "denied." However, some policies list ICD-9 codes on an exclusionary basis, meaning that covered diagnoses are any ICD-9 codes not listed under "denied" or "do not support medical necessity."

"Another advantage of the national coverage policies is the inclusion of ICD-9 symptom codes [780-789]," Werner comments. Many LMRPs include only diagnostic ICD-9 codes, making it difficult to be paid for services when the results do not indicate pathologic findings. "Including the ICD-9 codes for signs and symptoms will allow reimbursement when a test is ordered based on legitimate clinical indications, regardless of the final results," Werner says. Documentation in the medical record must support any diagnosis or procedure codes submitted.

"The Final Rule also includes specific coding guidelines as part of the coverage policies, which provide very concrete direction for reporting these services," Castillo says. For example, the policy for HIV viral load testing (87536, HIV-1, quantification; or 87539, HIV-2 quantification) states that CPT codes for quantification should not be used simultaneously with other nucleic acid detection codes for HIV-1 (87534, HIV-1, direct probe technique; or 87535, HIV-1 amplified probe technique) or HIV-2 (87537, HIV-2, direct probe technique; or 87538, HIV-2, amplified probe technique).

The policy for HIV diagnosis testing provides another example of coding-specific direction given in the national coverage decisions. The policy states that 86701 (Antibody; HIV-1) or 86703 (Antibody; HIV-1 and HIV-2, single assay) is covered for initial testing when clinical suspicion of HIV exists, while 86702 (Antibody; HIV-2) is covered only when 86701 is negative. Further, 86689 (HTLV or HIV antibody, confirmatory test [e.g., Western Blot]) is covered only for samples repeatedly positive by 86701, 86702 or 86703.

Some of the specific coding instructions indicate which ICD-9 codes are required for coverage for a particular test under certain circumstances. For example, coding directions for PTT (85730, Thromboplastin time, partial [PTT]; plasma or whole blood) state, "When patients are being converted from heparin therapy to warfarin therapy, use V58.61 (Long-term [current] use of anticoagulants) to document the medical necessity of the PTT." Similarly, coding instructions for collagen cross links (82523, Collagen cross links, any method) state, "When the indication for the test is long-term administration of glucocorticosteroids, use V58.69 (Long-term [current] use of other medications)."

"Coding instructions such as these will become very important for reimbursement once these policies are implemented," Castillo says. "Just as Medicare payment for screening Pap smears requires reporting specific diagnosis codes, in the same way Medicare payment for tests listed in these new national policies will require following the specific coding instructions given."

Get Ready to Implement Changes

"Laboratories will have to prepare for the new policies by updating existing systems to accommodate any changes," Baillie says. "They may have to engage the assistance of local Medicare carriers and possibly independent vendors to accomplish this goal."

Werner agrees: "Most labs have multiple systems in place to ensure that only medically necessary tests are performed and that they are accurately reported. For example, we publish and update LMRP manuals for our clients to minimize the number of orders that we get for noncovered tests. We also have a laboratory system database that includes current LMRP rules to detect noncovered tests before they are performed." According to Werner, these systems will have to be scrutinized and updated to incorporate any differences between the new national coverage policies and the existing LMRPs.

For example, the new national coverage policy for 86304 (Immunoassay for tumor antigen, quantitative; CA 125) includes a much smaller list of covered diagnoses than the LMRP for Kansas Medicare. The national coverage policy states that CA 125 is indicated for patients with ovarian cancer, as well as carcinoma of the fallopian tube, endometrium and endocervix. Covered diagnoses include ICD-9 codes for only these conditions (180.0, 182.0, 183.0, 183.2, 183.8, 184.8, 198.6, 198.82) or suspected conditions (236.0-236.3, Neoplasm of uncertain behavior of female genital organs) or history (V10.43-V10.44, Personal history of malignant neoplasm of female genital organs).

However, the LMRP for Kansas, Nebraska and Western Missouri, found at http://www.kansasmedicare. com/part_B/lmrp, indicates broader coverage, including ICD-9 codes for carcinoma of the pancreas (157.0-157.9), neoplasm of the trachea/lung (162.0-162.9) and breast cancer (174.0-175.9), among others. Under the new national policy, CA 125 performed for these diagnoses would fall in the category of "does not support medical necessity and would not automatically be covered." Labs would have to submit additional documentation for consideration of coverage for these diagnoses.

On the billing side, many laboratories also have software that screens for reporting errors such as disagreement between ICD-9 and CPT codes. These systems must also be updated to accommodate any changes under the new national coverage policies. "Whether a lab has a computerized system that checks for these types of errors or not, coders and billers will need to be educated about the new rules," Werner says. "Although these changes may be costly, the national coverage policies will hopefully prove beneficial in the long run as we avoid the complication of meeting multiple, conflicting LMRPs."