Pathology/Lab Coding Alert

Question: When we run a complete blood count with automated differential, sometimes we have to reflex to a manual differential. For instance, if variant lymphocytes exceed 15 percent, or nucleated red blood cells exceed 5 percent in the sample, we add the manual differential count. Can we report this as 85027 and 85007?

Codify Subscriber

Answer: No, for Medicare and most other payers, you should not separately bill for a reflex manual differential if the primary physician ordered a CBC and automated differential. You should code the procedure just as you would if you didn’t reflex to the manual diff, using 85025 (Blood count; complete [CBC], automated [Hgb, Hct, RBC, WBC and platelet count] and automated differential WBC count).

According to CMS instruction, even if the CBC “reflexes” to a manual differential, you should bill Medicare only for the ordered test — 85025

Avoid: You should not take an order for 85025 and change it to 85027 (Blood count; complete [CBC], automated [Hgb, Hct, RBC, WBC and platelet count]) plus 85007 (Blood count; blood smear, microscopic examination with manual differential WBC count), even though that more accurately describes the tests your lab performs,

Obey CCI: 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.

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.