Pathology/Lab Coding Alert

Know when and how to override edit pairs.

Quarterly updates to Medicare’s National Correct Coding Initiative (NCCI) provide both immediate coding restrictions you need to know, plus an opportunity to refresh your coding knowledge for clean lab claims.

Read on for our experts’ advice about how to incorporate the latest NCCI update into your lab-service reporting.

Recharge your NCCI Know-How

The Centers for Medicare and Medicaid Services (CMS) implemented NCCI to “prevent improper payment when incorrect code combinations are reported” by assembling “code pairs that should not be reported together for a number of reasons,” according to https://www.cms.gov/Medicare/Coding/NationalCorrectCodInitEd.

The NCCI sets a methodology to identify unbundling and over-coding scenarios, according to Chelle Johnson, CPMA, CPC, CPCO, CPPM, CEMC, AAPC Fellow, billing/ credentialing/auditing/coding coordinator at County of Stanislaus Health Services Agency in Modesto, California.

PTP: The procedure-to-procedure (PTP) edits link in two columns, pairs of codes (called edit pairs, or bundles) that you should not report together for a single procedure involving the same anatomic site at the same encounter by the same healthcare provider.

CMS assigns Column 1 status to the comprehensive service and Column 2 status to a code regarded as being a component of, or mutually exclusive with, the Column 1 service.

CMS then assigns one of three modifier indicators to each edit pair — “0,” “1,” or “9.” Modifier indicator 9 means the edit pair has been deleted, so you don’t need to worry about that coding restriction. But you should beware of modifier indicator 0, which means you cannot override the edit pair under any circumstances.

Opportunity: A modifier indicator of 1 means you can report both codes of the edit pair using an appropriate modifier, as long as you provide documentation that the procedures are distinct due to a difference such as encounter, site, procedure, or provider.

The NCCI-associated modifiers that labs are most likely to use are the following:

• 91 (Repeat Clinical Diagnostic Laboratory Test)
• 59 (Distinct Procedural Service)
• XE (Separate encounter, a service that is distinct because it occurred during a separate encounter)
• XS (Separate structure, a service that is distinct because it was performed on a separate organ/structure)
• XP (Separate practitioner, a service that is distinct because it was performed by a different practitioner)
• XU (Unusual non-overlapping service, the use of a service that is distinct because it does not overlap usual components of the main service)

How to choose: “Before immediately appending modifier 59, always review the modifier lists for a more appropriate/specific modifier,” says Christina Neighbors, MA, CPC, CCC, Coding Quality Auditor for Conifer Health Solutions, Coding Quality & Education Department. “It is extremely important to use the X{EPSU} modifiers accordingly.”

Don’t Double-Dip for Respiratory Virus Testing

With so many new codes for lab testing related to SARS-CoV-2 and other respiratory viruses, the latest NCCI update, version 27.1, adds some bundles you need to know about.

0202U: The code that accounts for many of the new edit pairs is proprietary laboratory analysis (PLA) code 0202U (Infectious disease (bacterial or viral respiratory tract infection), pathogen-specific nucleic acid (DNA or RNA), 22 targets including severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), qualitative RT-PCR, nasopharyngeal swab, each pathogen reported as detected or not detected). The code was effective May 20, 2020, and describes the proprietary test, BioFire^® FilmArray^® Respiratory Panel 2.1.

NCCI 27.1 lists 0202U as a column 2 code with more than 30 other PLA codes that use similar methodology or interrogate similar genes, plus the complete range of Tier 1 molecular pathology codes 81105-81383, as well as 87153 (Culture, typing; identification by nucleic acid sequencing method, each isolate (eg, sequencing of the 16S rRNA gene)). All those edit pairs show a modifier indicator of 1.

NCCI 27.1 also lists 0202U as a column 1 code with Tier 2 molecular pathology codes 81404, 81407, and 81408 (Molecular pathology procedure, Level …), as well as codes 87149 and 87150 (Culture, typing …), still with a modifier indicator of 1.

Caution: Your biggest concern should be that NCCI now bundles 0202U as a column 1 code with 87260 (Infectious agent antigen detection by immunofluorescent technique; adenovirus) , 87280 (… respiratory syncytial virus), and 87301 (Infectious agent antigen detection by immunoassay technique, (eg, enzyme immunoassay [EIA], enzyme-linked immunosorbent assay [ELISA], fluorescence immunoassay [FIA], immunochemiluminometric assay [IMCA]) qualitative or semiquantitative; adenovirus enteric types 40/41) with modifier indicator 0, because the 0202U test also evaluates for adenovirus and respiratory syncytial virus.

Also: NCCI 27.1 adds other edit pairs with a modifier indicator of 0 involving other PLA codes. The following lists shows the procedure similarities for these code pairs:

• 0211U (Oncology (pan-tumor), DNA and RNA by next-generation sequencing, utilizing formalin-fixed paraffin-embedded tissue, interpretative report … with therapy association) bundled with 0019U (Oncology, RNA, gene expression by whole transcriptome sequencing, formalin-fixed paraffin-embedded tissue … reported as potential targets for therapeutic agents)
• 0212U (Rare diseases (constitutional/heritable disorders), whole genome and mitochondrial DNA sequence analysis … blood or saliva, identification and categorization of genetic variants, proband) and 0213U, which is identical to 0212U except it is for each comparator (such as parent or sibling) — bundled with 81460 (Whole mitochondrial genome …). NCCI also bundles 0213U with +81426 (Genome (eg, unexplained constitutional or heritable disorder or syndrome); sequence analysis, each comparator genome (eg, parents, siblings) …).
• 0215U (Rare diseases (constitutional/heritable disorders), whole exome … each comparator exome (eg, parent, sibling)) bundled with +81416 (Exome (eg, unexplained constitutional or heritable disorder or syndrome); sequence analysis, each comparator exome (eg, parents, siblings) …)
• 0217U (Neurology (inherited ataxias), genomic DNA sequence analysis of 51 genes …) bundled with 81284 (FXN (frataxin) (eg, Friedreich ataxia) gene analysis …)
• 0218U (Neurology (muscular dystrophy), DMD gene sequence analysis …) bundled with 81161 (DMD (dystrophin) (eg, Duchenne/Becker muscular dystrophy) deletion analysis …)

Key: When two lab tests evaluate all or part of the same analyte and/or use the same methodology, NCCI typically bundles those codes with a 0 modifier indicator, meaning that you should not report the codes together, but should choose the single code that most accurately describes the test performed.