Pathology/Lab Coding Alert

Look for "unlisted antigen" code on the CLFS

If you are an independent lab billing Medicare, you probably didn’t get paid for 86586 last year when you counted an unlisted cell-marker as part of an immunology-panel. Now you can--just bill for 86586, which is newly added to the Clinical Laboratory Fee Schedule (CLFS), priced at $52.70.

Code for Each Immunology Cell Count

When available, you should always use specific codes for markers such as B cells (86355, B cells, total count) that are part of an immunodeficiency or related panel. “But when the panel contains markers ‘not otherwise specified’ by a separate code, you should use 86586 [Unlisted antigen, each], according to my communication with the AMA,” says Dennis Padget, MBA, CPA, FHFMA, president of DLPadget Enterprises Inc., a pathology business practices publishing company in Simpsonville, Ky.

But if you billed 86586 last year as an independent lab or a hospital lab billing for outreach patient testing, you probably didn’t get paid. The discrepancy occurred due to an oversight that listed 86586 on the hospital Outpatient Prospective Payment System (OPPS) but not on the CLFS. That means independent labs couldn’t get paid for unlisted markers, and hospital labs could only get paid for outpatients. “In other words, labs that can’t bill under the OPPS fee schedule--basically all commercial independent labs--have had no assured or efficient way to get paid for unlisted antigens/antibodies for almost a year,” Padget says. 

CMS Answers Appeal

Thanks to Padget’s appeal to CMS, independent labs and hospitals for outpatients and outreach patients will finally get proper payment from Medicare for “not-otherwise-specified” flow cytometry markers they run for immune dysfunction and related tests. CMS has agreed to pay the unlisted markers at the same rate and in the same way that Medicare pays for specified immunology markers (T cell, B cell, natural killer cell and stem cell).

In the Nov. 10, 2005 Federal Register, CMS agrees with Padget’s request regarding 86586, consenting to “pay for this code under the clinical lab fee schedule in CY 2006. This code will therefore not be paid under the OPPS in 2006.” The national payment rate for 86586 in the 2006 CLFS is $52.70.

Labs will once again get paid for CD28, HLA-DR, CD38, and other “unlisted” markers with immunodeficiency and related panels starting Jan. 1.