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.

Remember that carriers would expect circumstances for overriding the CCI edit pairs to be rare. Overuse of modifiers such as -59 can send up a red flag for audits, so they should be used carefully and discriminately after ensuring that the appropriate documentation exists to back up the claim.

Pathology Consult With Clinical Laboratory Tests

About 700 new code edit pairs in CCI Version 6.3 exclude reporting certain clinical laboratory tests with the clinical laboratory pathology consultation codes 80500 (clinical pathology consultation; limited, without review of patients history and medical records) and 80502 (clinical pathology consultation; comprehensive, for a complex diagnostic problem, with review of patients history and medical records). These include a few of the lab panels, such as 80061 (lipid panel), and all of the evocative/suppression testing codes (80400-80440). Select chemistry codes, such as blood gases (82803-82820) and molecular diagnostics (83890-83912), also can no longer be reported with a clinical pathology consultation for the same patient on the same day.

Further, most hematology and coagulation codes (85002-85999) and many immunology codes in the range 86000-86384 have the same restriction from the pathology consultation codes under CCI Version 6.3. Many microbiology codes (87001-87999) also have new edit pairs excluding coding with a pathology consultation, including all of the codes for infectious agent detection by nucleic acid (87470-87799). The last group of codes that is largely restricted from use with 80500 and 80502 is the cytogenic studies (88230-88299). Version 6.3 does not place this consultation limitation on most cytopathology (88104-88199) or surgical pathology (88300-88399) services.

The fact that these new edit pairs have been created in CCIs comprehensive and component list indicates that the rendering of a pathologists opinion is considered bundled with (or a component of) these clinical laboratory procedures. As such, listing a consultation code for a simple test interpretation by a pathologist would be inappropriate.

There may be rare cases that meet the criteria for a separately reportable clinical pathology consultation in addition to one of these clinical laboratory tests. The criteria are:

The patients attending physician must request the consultation.

The consultation must relate to an abnormal test result, based on the condition of the patient.

A clinical pathology consultation requires the exercise of medical judgment by the consulting pathologist.

The consultation should result in a written report that is included in the patients medical record.

Because all of these new edits are listed with the superscript (1), meaning that the code can be modified, the appropriate use of modifiers can override the edits if the criteria for a consultation are met. Modifier -59 should be used to indicate that a clinical pathology consultation was conducted separately from the performance and interpretation of the test.

Reporting E/M With Pathology Services

More than 3,500 new code edit pairs in CCI Version 6.3 exclude reporting certain pathology services with the majority of the E/M codes. Although the restriction is placed only on 54 pathology services, the large number of E/M codes results in an extensive new list of edit pairs. The restricted services involve evocative/suppression testing, certain anatomic pathology codes and some blood banking/transfusion medicine codes.

This new restriction shouldnt have a significant impact on coding for many anatomic pathology practices because most pathologists do not report the E/M codes for these services, says R.M. Stainton Jr., MD, president of Doctors Anatomic Pathology Services, an independent pathology laboratory in Jonesboro, Ark.

The codes that are newly restricted from reporting with E/M services include 85095 (bone marrow; aspiration only) and 85102 (bone marrow biopsy, needle or trocar). When a pathologist from our practice conducts a bone marrow aspiration or biopsy, the referring physician is the individual responsible for the patient examination and care. In these cases, we dont use the E/M codes because we dont provide that service, he continues.

Under the revised CCI edits, fine needle aspiration (FNA) can no longer be reported with E/M services for the same patient on the same day without the use of modifiers. The restricted codes are 88170 (fine needle aspiration with or without preparation of smears; superficial tissue [e.g., thyroid, breast, prostate]) and 88171 (fine needle aspiration with or without preparation of smears; deep tissue under radiologic guidance). As with bone marrow aspiration or biopsy, we would not typically provide E/M services for patients when we conduct an FNA, says Stainton. Similarly, we dont report E/M services with the codes for pathology consultation during surgery (88170 and 88171), which are also restricted under the new edits.

On the other hand, blood bank physicians and hematologists involved with transfusion medicine may be impacted by the new CCI constraints for reporting E/M services with certain pathology codes. Three blood bank physician codes are restricted under the new edits:

86077 blood bank physician services; difficult cross match and/or evaluation of irregular antibody(s), interpretation and written report

86078 blood bank physician services; investigation of transfusion reaction including suspicion of transmissible disease, interpretation and written report

86079 blood bank physician services; authorization for deviation from standard blood banking procedures (e.g., use of outdated blood, transfusion of Rh incompatible units), with written report

The codes for autologous blood collection represent additional edit pairs in Version 6.3. These codes are: 86890 (autologous blood or component, collection processing and storage; predeposited) and 86891 (autologous blood or component, collection processing and storage; intra- or postoperative salvage).

Hematologists may provide patient E/M while furnishing some of these transfusion and blood bank services. This might include patient examination, writing progress notes, and giving clinical orders regarding such issues as fluid replacement. But the new CCI edits indicate that the E/M services are considered bundled for codes 86077-86079 and 86890-86891. Practitioners who have routinely coded separately for the E/M services may need to reconsider that practice under the new CCI edits. But with appropriate documentation of separate E/M services, these edit pairs can be overridden with a modifier, according to the superscript (1) assigned in CCI 6.3. The appropriate modifier would be -25 (significant, separately identifiable E/M service by the same physician on the same day of the procedure or other service).

Although the additions to the pathology section of CCI Version 6.3 appear massive, most of the changes fall into two categories. Many pathology services are now restricted from reporting with clinical pathology consultation codes (80500-80502) and/or E/M codes (mainly codes 99201-99350). But because the new edit pairs are listed with the superscript (1), coders can override the edits by using modifier -59 or -25 when supported by documentation for a separate, medically necessary service.