Pathology/Lab Coding Alert

Decipher 6 edit-pair explanations

Just because National Correct Coding Initiative version 12.2 adds only one new code pair for laboratory doesn't mean you can afford to ignore the edits. Now is the perfect time to take a breather from updating edits -- and take a primer on bundling logic so you can avoid unbundling snares.

-Standard Policy Statement- Reveals the -Why-

 NCCI links a -standard policy statement- to each code pair, and the NCCI Policy Manual explains the meaning of these standards. -If you understand the reason certain codes are bundled, you can better determine what circumstances might warrant unbundling those services with a modifier,- says William Dettwyler, MT-AMT, president of Codus Medicus, a laboratory coding consulting firm in Salem, Ore. Here are the top-six standard policy statements for labs:

1. HCPCS/CPT Procedure Code Definition

NCCI lists this policy statement when one code is part of another based on the descriptor language. In many cases, that's because an indented code includes all of the service described by the main entry preceding a semicolon. For example, NCCI bundles 88329 (Pathology consultation during surgery;) with 88334 (... cytologic examination [e.g., touch prep, squash prep], each additional site). Indented code 88334 includes the service of the main-entry code 88329.

2. HCPCS/CPT Coding Manual Instruction/Guideline

At the start of major sections or subsections or preceding or following a series of codes, CPT provides cross-references and guidance to assist providers in selecting the appropriate codes. NCCI forms edit pairs when reporting two codes together would be contrary to these CPT instructions.
 
For instance: A text note following fine-needle aspiration (FNA) codes states, -Do not report 88172, 88173 in conjunction with 88333 and 88334 for the same specimen.- -That's why you can only override the edit pair if the pathologist interprets an FNA from one source [88173, Cytopathology, evaluation of fine needle aspirate; interpretation and report] and evaluates an intraoperative touch prep from a separate specimen [88333] on the same day,- Dettwyler says.

3. Misuse of Column 2 Code With Column 1 Code

When CMS identifies codes from different parts of CPT that providers might mistakenly construe to describe a similar service, an NCCI edit will prohibit the code pair under the -misuse of column 2 code with column 1 code- policy.
 
New in NCCI 12.2: Under this policy, the latest version of NCCI bundles 86580 (Skin test; TB, intradermal) with 90772 (Therapeutic, prophylactic or diagnostic injection [specify substance or drug]; subcutaneous or intramuscular). Reporting 90772 for administering the intradermal TB test misconstrues the intention of the code, which is for reporting an injection with a drug code. You should not report 86580 and 90772 together for the single TB test.

4. Standards of Medical/Surgical Practice

Each CPT code includes generic activities that the provider must always perform to accomplish the procedure. You can't separately code an activity that is a standard part of a particular procedure.
 
Watch for: Under this policy, NCCI bundles lab consultation code 80500 (Clinical pathology consultation; limited, without review of patient's history and medical records) with many clinical lab tests, such as 83700 (Lipoprotein, blood; electrophoretic separation and quantitation), so that you don't bill separately for a pathologist's medical direction and supervision of clinical lab tests -- an integral part of any lab test service. 
 
Do this: But that doesn't mean a pathologist can't charge for an 80500 consultation related to a clinical lab
test when he meets and documents the requirements for a consultation. -If the attending physician requests a consultation on an abnormal lab test result, and the pathologist renders a professional opinion and files a report, you can report 80500 with the bundled lab codes by using modifier 59 (Distinct procedural service),- Dettwyler says.

5. Mutually Exclusive Procedures

NCCI developed an independent table for mutually exclusive edits to bundle services that you could not reasonably perform at the same anatomic site or patient encounter. For labs, these bundles often represent two different methods for obtaining similar diagnostic information -- the lab will do one test or the other.
 
For example: NCCI lists a mutually exclusive edit pair for 83700 and 83701 (Lipoprotein, blood; high- resolution fractionation and quantitation of lipoproteins including lipoprotein subclasses when performed [e.g., electrophoresis, ultracentrifugation]). The codes list two different methods for quantifying serum lipoprotein, and the lab would not perform both tests.

6. More Extensive Procedure

Edit pairs keep you from listing two tests that are basically the same, except that one represents higher  complexity. NCCI says that you should include the service from the less-extensive procedure in the more-extensive procedure.
 
That's why NCCI bundles 83718 (Lipoprotein, direct measurement; high-density cholesterol [HDL cholesterol]) with 83701, which is the more-extensive procedure that includes an HDL measurement.
 
Free resource: You can access the NCCI edits without cost at the CMS Web site www.cms.hhs.gov/NationalCorrectCodInitEd/, says Laureen Jandroep, OTR, CPC, CCS-P, CPC-H, CCS, director and senior instructor for CRN Institute in Absecon, N.J. You-ll also find links to documents that explain the edits, including the NCCI Policy Manual for Part B Medicare Carriers, the Medicare Carriers Manual, and an NCCI Question-and-Answer page. NCCI 12.2 is effective July 1.