Pathology/Lab Coding Alert

The number of pathology/laboratory edit pairs has more than doubled in Version 6.3 of the Correct Coding Initiative (CCI), which goes into effect Oct. 30, 2000. Coders need to be aware of the changes and prepared to override the edits when it is medically necessary to provide the paired services to the same patient on the same day. You can ensure reimbursement for these services by appropriately using modifiers to override the edits.

The many additional pathology code pairs in CCI Version 6.3 fall into two categories. First, the two codes for clinical pathology consultations (80500 and 80502) can no longer be reported with many clinical laboratory tests. Second, certain pathology services can no longer be reported with most of the evaluation and management (E/M) codes.

CCI Defines Inappropriate Coding

In response to direction from Congress, the Health Care Financing Administration (HCFA) initiated the national CCI edits in 1996 to reduce Medicare program expenditures by detecting inappropriate coding on claims, and denying payment. The CCI edits are a list of code pairs that Medicare will not reimburse together for the same patient on the same day because they represent services that are bundled or would not ordinarily be performed together, explains Laurie Castillo, MA, CPC, CPC-H, CCS-P, member of the National Advisory Board of the American Academy of Professional Coders (AAPC) and president of its Northern Virginia Chapter in Manassas. Reporting two of these codes together for the same service represents fraudulent unbundling, which is the practice of breaking down a single procedure into its component parts and billing for additional services.

However, there are times when two of these codes might legitimately be coded together, if they represent two services that are distinct and independent from each other. This may represent procedures carried out on separate body sites, or during different times of the same day. To indicate that the codes represent separate services as opposed to unbundling of a single service, coders should use appropriate modifiers, such as -59 (distinct procedural service), she advises. Modifier -59 was created as a response to the CCI edits and can override most, but not all, bundling combinations.

The CCI uses indicators to show which codes may appropriately use modifiers, if documentation exists to support the claim that the procedures were distinct and independent. Whether codes can be reported together using modifiers under appropriate circumstances is indicated by the presence of a superscript number next to the codes in the CCI edit list. If the codes can be modified, they will have an indicator (1) beside them. If they cant, indicator (0) is shown.
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