Pathology/Lab Coding Alert

Medical necessity and modifiers spell success

Word on the street says denials for three lab tests -- CPT 86318 , 87804 and 85610 -- can plague physician office labs. New coverage rules might leave you holding the bag for these CLIA-waived tests -- unless you follow our insiders- advice to ensure snag-free payment.

-I am having trouble with 86318-QW especially,- says Brenda Phillips at Litchfield Medical Center in Pawley's Island, S.C. Implement this expert advice to make sure you capture CLIA-waived lab charges the first time around.

Overturn 87804-QW Duplicate Denials With 2 Strategies

Coding for last year's release of the influenza B test has dumfounded many coders who report both the A and B test. -The pharmaceutical representatives who sell the products say that you can bill the same code twice for the tests,- says Deb Chandler, BA, CPC, ACS-FP, CCP, with Family Physician Associates in Columbus, Ohio. But her group, which includes more than 150 physicians, started receiving numerous denials for the second 87804-QW (Infectious agent antigen detection by immunoassay with direct optical observation; influenza; CLIA-waived test) as a duplicate of the first.

Chandler and the drug reps, however, are right to bill influenza test A and B with two codes. Reason: Influenza test B is a different lab test from influenza test A. Each test detects a different type of influenza antigen -- A and B -- according to Tests Granted Waived Status Under CLIA, which lists Binax's tests use as:

- Binax Now Flu Test A -- Qualitative detection of influenza type A antigen in nasal wash and nasopharyngeal swab specimens
- Binax Now Flu Test B -- Qualitative detection of influenza type B antigen in nasal wash and nasopharyngeal swab specimens.

Success: Today, Chandler's 87804-QW denials are mainly a problem of the past thanks to two strategies:

1. Attaching modifier 59 (Distinct procedural service) to the second test B code. -We-ve been using modifier 59 to indicate that the second test is separate from the first with pretty good results,- Chandler says.

2. Creating a form explanation letter. -I took a proactive approach and wrote the insurance company a letter explaining what the two codes are for,- Chandler says. And her effort paid off: -The insurer paid both tests,- she says.

Consult LMRPs to Unlock 86318 Payment

Sometimes a policy, not a modifier, explains a lab test denial. Phillips- payment trouble with 86318-QW (Immunoassay for infectious agent antibody, qualitative or semiquantitative, single-step method [e.g., reagent strip]) sounds like a diagnostic issue, says Annette Grady, CPC, CPC-H, CPC-P, OS, director of educational services for Coding Metrix Inc. in North Dakota. Modifier QW (CLIA waived test) became effective on this code April 30, she says.

Most likely, the diagnosis that Phillips is using with 86318-QW doesn't meet the insurer's criteria. -A few states have local medical review policies (LMRPs) that allow a very select number of ICD-9 codes with 86318-QW,- Grady says.

Important: The 86318 LMRPs are by carrier, Grady says. -No national medical-necessity policy exists on the lab test code.-

Remedy: You have to watch for local coverage items with the H. pylori reagent strip test code. If the coder doesn't use the specific carrier-accepted diagnoses, you won't get paid, Grady says.

Some of the ICD-9 codes that will unlock payment for 86318-QW include:

- 041.86 -- Other specified bacterial infections; Helicobacter pylori (H. pylori)
- 151.0-151.9 -- Malignant neoplasm of stomach.

But remember -- you can only report a diagnosis that the physician documents in the medical record.

CMS Green Lights Coumadin, Not Pre-Op PT Diagnoses

Coding for prothrombin time (PT) testing (85610-QW, Prothrombin time) can also create a payment hurdle. If you-re a waived-status lab under the Clinical Laboratory Improvement Amendments (CLIA) and you-re getting denials even though you-re using modifier QW, something else must be wrong. Two diagnostic mistakes could be at the root of the problem.

1. List reason for blood-thinner: Physicians often order PT testing to check a patient's bleeding rate when she is on blood-thinning medication, such as Coumadin. In these cases, experts suggest snag-free claims should contain two diagnoses.

To report the primary diagnosis in these situations, you should know your physician's medical reason for giving the test, says Kathy Pride, CPC, CCS-P, director of consulting and training for QuadraMed in Reston, Va.

Often, physicians list V58.61 (Long-term [current] use of anticoagulants). When you use this code as the primary diagnosis, consider including a secondary ICD-9 code to indicate the reason for using the anticoagulant, such as 427.31 (Atrial fibrillation).
 
Be sure the diagnoses you-ve listed on the claim form match those the ordering physician documented in the medical record regarding the service billed, she says.

2. Be careful: CMS will not pay for PT tests with preoperative examination diagnoses V72.81-V72.85 (Other specified examinations). These five ICD-9 codes indicate that the physician ordered the tests without signs or symptoms. Thus, Medicare considers the tests -screenings- and, therefore, a noncovered service.

Solution: If, however, the patient has a sign, symptom or past history of disease that indicates an increased surgical risk, Medicare will cover the PT tests, states the national coverage determination (NCD). CMS will reimburse 85610 for several conditions that potentially indicate bleeding problems, such as V15.1 (Personal history of surgery to heart and great vessels).

Medicare will also cover the tests if the patient is taking anticoagulant medication (V58.61, Long-term [current] use of anticoagulants). Keep in mind: CMS is also considering adding 289.81 (Primary hypercoagulable state) as a covered indication for prothrombin time testing.