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 [...]