Pathology/Lab Coding Alert

Question: Medicare requires a diagnostic lab test to be ordered by a treating provider. It must also be medically necessary for diagnosis or treatment. What is a legitimate order? Sometimes we perform additional tests to reach a diagnosis that is not requested. Will Medicare cover these?

Nevada Subscriber

 
Answer: In an update to Medicare Carriers Manual (MCM) Part 3, new section 15021 provides direction on ordering diagnostic tests. The update, Transmittal 1725, is available on the Internet at www.hcfa.gov/pubforms/ transmit/R1725B3.pdf.
 
Section 15021 states, The treating physician/practitioner must order all diagnostic tests furnished to a beneficiary who is not an institutional inpatient or outpatient. A testing facility that furnishes a diagnostic test ordered by the treating physician/practitioner may not change the diagnostic test or perform an additional diagnostic test without a new order.
 
CMS includes laboratory tests in the definition of diagnostic tests and has laboratories and pathologists in the definition of testing facility. Further, the new MCM section defines treating physician or practitioner (e.g., nurse practitioner or physician assistant) as one who consults or treats a beneficiary for a specific medical problem and uses the results of diagnostic tests to that end.
 
The order or request for a diagnostic test may be communicated by a written document signed by the treating physician or practitioner, which is faxed, mailed or hand-delivered to the testing facility. The request may also be communicated by e-mail or telephone from the treating physician/practitioner to the testing facility. A telephone order must be documented in writing by the treating physician/practitioners office and the testing facility. 
 
The prohibition on conducting tests that are not specifically ordered could be problematic for pathologists and labs if CMS did not provide further explanation and exceptions. Although the treating physician may sometimes condition-ally request additional tests based on the first set of results, the pathologist must often perform additional tests that are not specifically requested by the treating physician. When certain criteria are met, pathologists may perform tests that are not specifically requested under section 15021 F: Surgical/Cytopathology Exception.
 
For a beneficiary who is not a hospital inpatient or outpatient, this exception allows the pathologist from a hospital or an independent lab to perform all tests necessary for a complete diagnosis, even if they are not specifically requested. The exception acknowledges the reality that when pathology specimens are submitted for evaluation, the requesting physician does not order a specific pathology service. In addition to the evaluation, the pathologist may need to conduct additional tests, such as special stains, to reach a diagnosis. The following criteria must be met to report tests not specifically requested:

 1. The test is medically necessary for reaching a complete diagnosis.
 2. The test results are communicated to the treating physician and used in the treatment of the patient.
 3. The pathologist provides documentation in the written report explaining why the tests were done.
 
For example, a pathologist at an independent laboratory receives a lung-wedge biopsy in a labeled container with a requisition signed by the surgeon. The requisition identifies the source of the tissue, and includes a brief history and description of clinical findings of lung mass (786.6). 
 
The pathologist evaluates the specimen (88307, level V - surgical pathology, gross and microscopic examination, lung, wedge biopsy) and finds a granuloma, indicating tuberculosis.
 
To ensure an accurate diagnosis of the lung mass, the pathologist orders a special stain of the tissue biopsy for acid fast bacilli, which is associated with tuberculosis, e.g., 010.0x, primary tuberculous infection. Although the stain is not specifically requested, the pathologist can carry out the service and report 88312 (special stains [list separately in addition to code for surgical pathology examination]; Group I for microorganisms [e.g., Gridley, acid fast, methenamine silver], each). This will be payable, even though it is not specifically ordered, because it meets the three criteria.