Pathology/Lab Coding Alert

"A rose by any other name would smell as sweet," according to the latest National Correct Coding Initiative (NCCI) edits, version 9.1. Labs have different test methods that supply similar results and you can no longer report many of those tests together.

Various codes describe tests for the same condition, organism or analyte because different lab methods exist to arrive at the same information or because different payers require diverse codes. More than 160 new pathology and laboratory edit pairs in NCCI 9.1 prohibit reporting these codes together.

"Because labs ordinarily perform just one test method on a specimen to identify a specific organism or condition, these edit pairs should not create a significant coding problem," says William Dettwyler, MT-AMT, coding analyst for Health Systems Concepts, a laboratory coding and compliance consulting firm in Longwood, Fla. But you need to be aware of the NCCI edit pair additions and how to override them if these services legitimately occur together. NCCI 9.1 is effective April 1 through June 30.

NCCI Points to Improper Coding

Medicare bundles procedures into NCCI edit pairs to indicate that one code is a component of a more comprehensive code, or that a physician would not ordinarily perform both services for the same patient on the same day (mutually exclusive services). "If the physician orders or carries out two medically necessary, distinct services of an NCCI code pair, Medicare may pay for both procedures if you report them with the appropriate modifier," says Laurie Castillo, MA, CPC, CPC-H, CCS-P, past member of the National Advisory Board of the American Academy of Professional Coders and vice president of ambulatory services, Health Revenue Assurance Associates in Chapel Hill, N.C.

"To indicate that codes represent separate services as opposed to unbundling of a single service, append modifier -59 (Distinct procedural service) to override the edit," Castillo says. For clinical lab tests conducted more than once a day, use modifier -91 (Repeat clinical diagnostic laboratory test). You can only override an NCCI edit with a modifier if the code pair shows a "1" in the modifier indicator column. A"0" modifier indicator means that you cannot override the edit pair.

Antigen Detection Methods Are Mutually Exclusive

NCCI 9.1 adds more than 80 edit pairs to the mutually exclusive list that prohibit reporting together two codes for detecting the same organism. This continues a trend from earlier NCCI edits and adds code pairs for the following organisms:

Chlamydia trachomatis

NCCI 9.1 bundles 87270 (Infectious agent antigen detection by immunofluorescent technique; Chlamydia trachomatis) and 87320 (Infectious agent antigen detection by enzyme immunoassay technique, qualitative or semiquan-titative, multiple step method; Chlamydia trachomatis) with each other and with each of the following codes:

New edit pairs also prohibit reporting any of these three codes together or reporting any of them with 87810 (Infectious agent detection by immunoassay with direct optical observation; Chlamydia trachomatis).

Influenza

The new NCCI pairs 87804 (Infectious agent antigen detection by immunoassay with direct optical observation; Influenza) with 87276 (Infectious agent antigen detection by immunofluorescent technique; Influenza A virus) and 87400 (Infectious agent antigen detection by enzyme immunoassay technique, qualitative or semiquantitative, multiple step method; Influenza, A or B, each). NCCI lists each of these edit pairs with a "0" modifier indicator.

Clostridium difficile

You can no longer report 87324 (Infectious agent antigen detection by enzyme immunoassay technique, qualitative or semiquantitative, multiple step method; Clostridium difficile toxin[s]) with 87803 (Infectious agent antigen detection by immunoassay with direct optical observation; Clostridium difficile toxin A). This edit pair has a "0" modifier indicator, meaning that you cannot override the edit.

HIV-2

The HIV-2 direct probe (87537, Infectious agent detection by nucleic acid [DNA or RNA]; HIV-2 direct probe technique) and amplified probe (87538 HIV-2, amplified probe technique) are bundled with the HIV-2 quantification (87539 HIV-2, quantification). You cannot use modifier -59 to report these services separately for the same session because the edit has a "0" modifier indicator.

Hepatitis C

NCCI 9.1 bundles 87520 (Infectious agent detection by nucleic acid [DNA or RNA]; hepatitis C, direct probe technique) with 87522 (... hepatitis C, quantification).

Streptococcus group A

You should not report the three nucleic acid detection codes for Streptococcus group Atogether, according to code pairs added to NCCI 9.1. These codes are 87650 (Infectious agent detection by nucleic acid [DNA or RNA]; Streptococcus, group A, direct probe technique), 87651 ( Streptococcus, group A, amplified probe technique) and 87652 ( Streptococcus, group A, quantification). Nor should you report any of these codes with 87880 (Infectious agent detection by immunoassay with direct optical observation; Streptococcus, group A). The new edit pairs also prohibit reporting 87651 or 87652 with 87430 (Infectious agent antigen detection by enzyme immunoassay technique, qualitative or semiquantitative, multiple step method; Streptococcus, group A). These code pairs also have a "0" modifier indicator.

Neisseria gonorrhoeae

NCCI 9.1 lists the three nucleic acid detection codes for Neisseria gonorrhoeae as mutually exclusive (87590, Infectious agent detection by nucleic acid [DNA or RNA]; Neisseria gonorrhoeae, direct probe technique; 87591 Neisseria gonorrhoeae, amplified probe technique; and 87592 Neisseria gonorrhoeae, quantification). Also do not report any of these codes with 87850 (Infectious agent detection by immunoassay with direct optical observation; Neisseria gonorrhoeae), according to the new edits.

Probes for Other Organisms

CPT 2003 lists "infectious agent detection by nucleic acid" codes for each of many organisms. NCCI 9.1 lists as mutually exclusive the direct probe, amplified probe and quantification codes for each organism listed in the code range 87470-87652. For example, do not report together Candida species codes 87480 ( Candida species, direct probe technique), 87481 ( Candida species, amplified probe technique) or 87482 ( Candida species, quantification).

"You would not ordinarily perform more than one of these tests for the same organism on the same day, so these edit pairs should not pose a problem," Dettwyler says. But NCCI 9.1 also lists as mutually exclusive the "not otherwise specified" codes (87797, Infectious agent detection by nucleic acid [DNA or RNA], not otherwise specified; direct probe technique, each organism; 87798 amplified probe technique, each organism; and 87799 quantification, each organism).

Labs might legitimately perform these tests together for different organisms. "These codes state 'each organism,'so if the lab uses multiple probes for different nonlisted species, you should report each probe separately," Dettwyler says. You should report the second and subsequent code(s) with modifier -59 to override the NCCI edit.

Similar Components Are Bundled Up

NCCI 9.1 adds comprehensive/component edit pairs for codes that describe similar services. Almost 80 of these edit pairs are for Pap tests. The others describe tests that are included in a larger service reported by another code.

The latest NCCI version also bundles 83721 (Lipoprotein, direct measurement; direct measurement, LDL cholesterol) as a component of 80061 (Lipid panel) and 82465 (Cholesterol, serum or whole blood, total). "Although direct LDL is not a component of the lipid panel, the NCCI edits may have bundled 83721 and 80061 because labs often report calculated LDL based on panel results," Dettwyler says. In some circumstances, however, such as panel triglyceride values that are too high to allow LDL calculation, the physician may order a separate direct LDL (83721), and you should use modifier -59 to override the edit pair.

NCCI 9.1 adds an edit pair for 88358 (Morphometric analysis; tumor) and 88342 (Immunocytochemistry [including tissue immunoperoxidase], each antibody). Labs typically apply at least one antibody stain before performing morphometric tumor analysis. "This may be a problem for some labs that currently report the 88342 stain in addition to the 88358 service," Dettwyler says. Although NCCI lists a "1" modifier indicator for the code pair, routinely overriding an edit pair is never wise.