Pathology/Lab Coding Alert

Avoid using truncated codes.

Dragging your feet to incorporate the latest ICD-10-CM codes could lead to denials for services covered by Medicare National Coverage Determinations (NCDs).

Change Request (CR) 11491 describes changes to four NCDs that might impact coverage for procedures carried out by your pathologist or clinical laboratory. Read on to see what you need to do by the April 1 effective date to make sure you’re submitting clean claims.

Grasp CR 11491 Background

The effective date of CR 11491 is April 1 — that’s the date the changes become active and you’re responsible for filing claims that abide by those rules. Medicare Administrative Contractor (MACs) should have implemented the changes into their systems in December last year involving ICD-10-CM changes that were effective Oct. 1, 2019.

Why the NCD change? “This CR [11491] constitutes a maintenance update of ICD-10 conversions and other coding updates specific to NCDs,” according to CMS. “These NCD coding changes are the result of newly available codes, coding revisions to NCDs released separately, or coding feedback received.”

Why are NCDs important? NCDs outline to what extent Medicare will cover specific medical services, procedures, or devices on a national basis. MACs may also rely on Local Coverage Determinations (LCDs) for coverage rules specific to their region.

Key: Pathologists must use the latest ICD-10-CM codes when assigning diagnoses based on findings from procedures such as tissues exams. Although clinical labs use diagnoses assigned by the ordering physician, the lab is still responsible for ensuring that their claims contain only current, specific codes.

You should regularly review LCDs and NCDs for quarterly updates, because this will assist you with accurate coding throughout the year, advises Christina Neighbors, MA, CPC, CCC, Coding Quality Auditor for Conifer Health Solutions, Coding Quality & Education Department.

NCD 190.11 “Home (PT/INR) Monitoring for Anticoagulation Management”

CMS adds to this NCD a host of new ICD-10-CM codes that demonstrate medical necessity for home prothrombin time (PT) testing, as follows:

• I26.93 and I26.94 for single or multiple (… subsegmental pulmonary embolism without acute cor pulmonale)
• I48.11, I48.19 for longstanding persistent or other persistent (… atrial fibrillation) instead of 148.1, because ICD-10-CM adds the 5th character for specificity
• I48.21 (Permanent atrial fibrillation) instead of I48.2, because ICD-10-CM adds the 5th character for specificity

Caution: Continuing to report I48.1 or I48.2, which are now truncated codes because they require a 5th character, would result in a claim denial

• I80.241, I80.242, and I80.243 for right, left, or bilateral (Phlebitis and thrombophlebitis of … peroneal vein)
• The following codes that represent a similar pattern of three, new, site-specific codes with a 6th character describing right, left, or bilateral:
  o  I80.251-I80.253 for Phlebitis and thrombophlebitis of … calf muscular vein
  o  I82.451-I80.453 for Acute embolism and thrombosis of … peroneal vein
  o  I82.461-I82.463 for Acute embolism and thrombosis of … calf muscular vein
  o  I82.551-I82.553 for Chronic embolism and thrombosis of … peroneal vein
  o  I82.561-I82.563 for Chronic embolism and thrombosis of … calf muscular vein

Before these new ICD-10-CM codes became effective, “coders could only report such conditions with other and unspecified codes,” says Sheri Poe Bernard, CPC, CRC, CDEO, CCS-P, author of the AMA book, Risk Adjustment Documentation and Coding.

Note: For each of these codes, the sixth character specifies specify right (1), left (2), or bilateral (3). . Continuing to report I48.1, which is a truncated code, would result in a claim denial

NCD 190.3 “Cytogenetic Studies”

If your lab performs cytogenetic studies to aid in diagnosis and treatment of certain types of lymphoma, you need to know that the 190.3 NCD adds C88.4 (Extranodal marginal zone B-cell lymphoma of mucosa-associated lymphoid tissue [MALT-lymphoma]) as a payable diagnosis for those tests.

For instance: Clinicians may order a lymph node chromosome analysis to aid in the differential diagnosis of lymphomas such as T-cell, B-cell, MALT, or Burkitt lymphomas. If the lab uses methods such as microscopic metaphase scanning and karyotyping, you might report codes such as 88262 (Chromosome analysis; count 15-20 cells, 2 karyotypes, with banding) and 88291 (Cytogenetics and molecular cytogenetics, interpretation and report) for the pathologist’s interpretation. Reporting the correct diagnosis code, such as C88.4, would be critical to demonstrate medical necessity for the test.