Pathology/Lab Coding Alert

Question: Medicare is denying an E/M code when our pathologist bills it with the procedures for a bone marrow aspiration. We have only recently been getting these denials. The pathologist performs a complete history and physical exam of the patient, including a detailed drug history in order to render a final diagnosis.

The final diagnosis is a combined clinical and pathological diagnosis. Orders are often written to complete the final evaluation. Which E/M code would be appropriate for these circumstances? Possibly an E/M code with a -25 modifier?

Illinois Subscriber

Answer: Bone marrow aspiration 85095 (bone marrow; aspiration only) was bundled with E/M services in the Correct Coding Initiative (CCI) edits version 6.3. This included E/M codes for many hospital inpatient or outpatient, and office visit services. However, these edits were suspended and should no longer affect your claims.

As long as you have documentation supporting the E/M service provided, you should be paid for that service. As to which E/M code to select: That depends on the circumstances surrounding the visit. E/M codes are divided into broad categories, such as office visits or hospital visits, and further subdivided by categories such as new patient and established patient. Within these categories, codes are assigned based on the content of the service, such as the level of history and examination and the medical decision-making involved. You should contact your carrier to discuss these denials. Some carriers have recommended using modifier -25 (significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service) to override inappropriate denials based on the implementation of CCI version 6.3 edits.

Answered by Laurie Castillo, MA, CPC, CPC-H, CCS-P, member of the National Advisory Board of the American Academy of Professional Coders.