Pathology/Lab Coding Alert
Avoid Billing "Reflex" Manual Diff
Question: In our lab, when a CBC with automated diff is ordered and then flagged by the instrument, the CBC (85025) is credited and a hemogram (85027) and manual diff (85007) are charged. Is this correct?
Michigan Subscriber
Answer: No, that’s not correct billing, particularly for Medicare. Even if the CBC “reflexes” to a manual differential, you should bill Medicare only for the ordered test — 85025 (Blood count; complete [CBC], automated [Hgb, Hct, RBC, WBC and platelet count] and automated differential WBC count).
Scenario: Sometimes the physician orders a CBC plus automated differential (85025), but the test result parameters indicate the need for additional evaluation, such as a manual differential count.
But that doesn’t mean you should add 85007 (Blood count; blood smear, microscopic examination with manual differential WBC count) to your 85025 claim. Correct Coding Initiative (CCI) edits prohibit billing together 85007 and 85025 “because this combination of codes results in duplicate payment for the differential WBC count,” according to the CCI Policy Manual. The 85025/85007 edit pair has a modifier indicator of “0,” meaning that you cannot override the edit pair under any circumstances.
Nor should you “switch” your claim from 85025 to 85027 (Blood count; complete [CBC], automated [Hgb, Hct, RBC, WBC and platelet count]) and 85007, as you mentioned doing. You shouldn’t change the coding from what the physician ordered (85025) to something different (85027 plus 85007) based on lab protocols.
Do this: For the reflex scenario, report the service as 85025 to Medicare. According to the CCI Policy Manual, “If, after a test is ordered and performed, additional related procedures are necessary to provide or confirm the result, these would be considered part of the ordered test.” Other payers may allow you to charge for the additional manual differential, but you should get that in writing.
Caveat: If the physician specifically orders a CBC and manual differential, you can report 85027 and 85007.
Pathology/Lab Coding Alert
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