Pathology/Lab Coding Alert

Discover which code pairs are now open to separate payment.

Medicare recently added more than 700 National Correct Coding Initiative (NCCI) Procedure-to-Procedure practitioner edits that apply to lab coding, and the proprietary laboratory analyses (PLA) codes are the star of the show, dominating additions, deletions, and revisions effective Jan. 1, 2024.

Here are the key points to remember to help ensure these new edits don’t cause trouble for your claims.

Reminder: Each PLA code describes only one unique lab test made by a specific manufacturer or performed by a specific lab. You can recognize the codes by their unique appearance of four digits followed by a U. When a PLA code is available to report a service, you must use that PLA code rather than another code, such as one from the 80000 range.

Know Which New Edits Have Modifier Indicator ‘0’

The vast majority of the new PLA NCCI edits have the modifier indicator “1,” but don’t make the mistake of assuming they all do. If you report both codes of an edit pair that has a “0” modifier indicator, Medicare will not pay you for the column 2 code even if you append a modifier.

As an example, there are more than 375 new edits with column 1 code 0392U (Drug metabolism (depression, anxiety, attention deficit hyperactivity disorder [ADHD]), gene-drug interactions, variant analysis of 16 genes, including deletion/duplication analysis of CYP2D6, reported as impact of gene-drug interaction for each drug). However, only 10 of those edits have a modifier indicator of “0,” such as edits bundling in the CYP2D6 gene analysis add-on codes +0071U to +0076U.

Takeaway: Before reporting two lab codes together, be sure to check whether there is an edit and, if so, what the modifier indicator is. Don’t consider overriding the edit if the modifier indicator is “0.”

Don’t Miss Modifier Indicator Changes

Medicare’s latest NCCI update changes the modifier indicators for only two edits, and both involve 0239U (Targeted genomic sequence analysis panel, solid organ neoplasm, cell-free DNA, analysis of 311 or more genes, interrogation for sequence variants, including substitutions, insertions, deletions, select rearrangements, and copy number variations).

The edits have 0239U in the column 1 position and bundle in 81449 (Solid organ neoplasm, genomic sequence analysis panel, 5-50 genes, interrogation for sequence variants and copy number variants or rearrangements, if performed; RNA analysis) and 81456 (Solid organ or hematolymphoid neoplasm or disorder, 51 or greater genes, genomic sequence analysis panel, interrogation for sequence variants and copy number variants or rearrangements, or isoform expression or mRNA expression levels, if performed; RNA analysis).

In 2023, these edits had a modifier indicator of “0,” so you could never override the edits. But as of Jan. 1, 2024, these edits have a modifier indicator of “1.”

Takeaway: You now may override the 0239U/81449 and 0239U/81456 edits with an NCCI-approved modifier when the documentation and circumstances support reporting the services separately. This change opens the opportunity to be paid for both codes.

Understand NCCI Manual Rules, Too

To protect your claims from NCCI edit problems, you should review edit changes every quarter so you have a general sense of the edits that affect you. You also should check your claims for NCCI edit issues before you submit them. But many coders forget that the NCCI edits don’t include every possible coding conflict. Medicare expects you to apply the rules in the National Correct Coding Initiative Policy Manual for Medicare Services, as well.

Chapter 10 of the manual is specific to path/lab services and includes tips like these for PLA codes:

• Many PLA codes represent DNA or RNA analytic methods that test or evaluate multiple genes or genetic regions at the same time. You should not separately report testing for the same gene or genetic region by a different methodology because Medicare does not allow separate payment for multiple methods to test for the same analyte.
• Similarly, you usually should not report a Tier 1 or Tier 2 molecular pathology procedure code at the same time as a PLA code if they involve testing for the same analyte.
• If a single lab procedure evaluates multiple genes using a next generation sequencing procedure, you should report only one unit of service of the PLA code.

Takeaway: Understanding Medicare’s reasons for not allowing you to report certain services together will help keep your claims clean. Medicare updates the NCCI manual each January. You can find links to the NCCI edits, manual, and other NCCI resources at www.cms.gov/medicare/coding-billing/ncci-medicare.