Pathology/Lab Coding Alert

Watch for numeric limits to Pap and PSA

Beginning Jan. 1, you-ll have to contend with a new set of coding -edits- -- separate from the already-established National Correct Coding Initiative (NCCI) edits -- that CMS will issue quarterly. Although the list contains no 80000 codes for this quarter, you-ll have to watch for unit edits for certain Medicare screening laboratory G codes.

Edits Prevent Gross Mistakes

The new -Medically Unlikely Edits- (MUEs) are a refined version of the -Medically Unbelievable Edits- that CMS initially proposed -- and then, due to provider concerns, withdrew -- in 2005.

-I was pleased that Medicare withdrew some of the proposed MUEs that would have been very problematic, such as a limit of two units of 88305 (Level IV -- Surgical pathology, gross and microscopic examination),- says Stan Werner, MT (ASCP), administrative director of Peterson Clinical Laboratory in Manhattan, Kan.

The goal of the new edits is to prevent overpayments caused by gross billing errors, usually as the result of clerical or billing system mistakes, said Niles R. Rosen, MD, medical director for Correct Coding Solutions LLC, which has worked hand-in-hand with CMS to develop the current edits, during a presentation at the AMA CPT and RBRVS 2007 Annual Symposium in Chicago.

-The MUEs will limit automatically the number of units of service you can bill for a service in any 24-hour period,- Rosen said. The maximum units of service for a given CPT code have not been assigned arbitrarily, but by using common-sense criteria.

Example: The edits will limit the claims for G0103 (Prostate cancer screening; prostate specific antigen test [PSA], total) to a single unit per calendar day. This makes sense because you would not run two screening PSA tests on the same day.

The first-quarter MUEs also limit screening cervical cytology G codes to one unit per day:

- G0123 -- Screening cytopathology, cervical or vaginal (any reporting system), collected in preservative fluid, automated thin layer preparation, screening by cytotechnologist under physician supervision

- G0124 -- Screening cytopathology, cervical or vaginal (any reporting system), collected in preservative fluid, automated thin layer preparation, requiring interpretation by physician

- G0141 -- Screening cytopathology smears, cervical or vaginal, performed by automated system, with manual rescreening, requiring interpretation by physician

- G0143 -- Screening cytopathology, cervical or vaginal (any reporting system), collected in preservative fluid, automated thin layer preparation, with manual screening and rescreening by cytotechnologist under physician supervision

- G0144 -- Screening cytopathology, cervical or vaginal (any reporting system), collected in preservative fluid, automated thin layer preparation, with screening by automated system, under physician supervision

- G0145 -- Screening cytopathology, cervical or vaginal (any reporting system), collected in preservative fluid, automated thin layer preparation, with screening by automated system and manual rescreening under physician supervision

- G0147 -- Screening cytopathology smears, cervical or vaginal, performed by automated system under physician supervision

- G0148 -- Screening cytopathology smears, cervical or vaginal, performed by automated system with manual rescreening.

-Limiting screening Pap codes to one per day should not be a big problem for labs in most cases,-  Werner says.
 
Potential problem: In rare cases, pathologists may have reason to perform multiple cervical/vaginal cytopathology screenings using G codes that the MUEs restrict to one unit of service per day. The College of American Pathologists (CAP) commented to CMS that pathologists must sometimes diagnose more than one cervical/vaginal cytopathology specimen in a single day -- such as patients with a history of in utero DES (diethylstilbestrol) exposure or patients with two cervixes.
 
Edits Operate per Line, Not per Claim

One advantage of the MUEs is that, if you do run afoul of the edits, you won't face a denial for your entire claim, but only the single line item that violates the MUE guidelines, Rosen said.

And you will be able to appeal MUE edit rejections if you think that you appropriately billed your claim and met the requirements of medical necessity.

-However,- Rosen said, -we have designed the edits such that there should be an absolute minimum of inappropriately rejected claims. The criteria we use are meant to catch egregious errors, not to prevent legitimate services from being paid.-

Like the NCCI, CMS will update the MUE quarterly, and they will be subject to continuing refinement. -CMS and Correct Coding Solutions welcome suggestions and comments from providers,- Rosen said.