Pathology/Lab Coding Alert
Report Ordering or Final Diagnosis on Medicare Claims?
When should you report the ordering physician's diagnosis, and when should you report the pathologist's diagnosis on a Medicare claim? That depends - diagnosis reporting is different for clinical diagnostic lab tests than for physician pathology service . Incorrectly reporting ICD9 Code could mean facing claim denials or fraud charges. New Medicare instructions implementing Health Insurance Portability and Accountability Act (HIPAA) ICD-9-CM coding requirements clarify how labs acquire and report diagnostic information from the ordering physician. Just don't confuse these directions with CMS instructions for physician pathology services, or you could be out of compliance. Labs Get Diagnosis From the Ordering Physician Beginning Oct.1, all Part B providers (except ambulance) must submit an ICD-9 code with all paper and electronic claims. That means physicians will comply with their 1997 Balanced Budget Act obligation to supply diagnostic information when ordering diagnostic tests, according to program memoranda B-03-045 and B-03-046. The notices provide specific direction for labs about how to get diagnostic information from the ordering physician. You can access the memos on the Internet at http://www.cms.gov/manuals/pm_trans/B03045.pdf and http://www.cms.gov/manuals/pm_trans/B03046.pdf. The memoranda provide ICD-9 coding instructions for labs, but the directions only apply when reporting clinical diagnostic tests, which include all those without a pathologist-provided interpretation and diagnosis. "Laboratories billing tests paid under the clinical laboratory fee schedule need to pay attention to these instructions for ICD-9 coding," says Dennis Padget, MBA, CPA, FHFMA, president of Padget & Associates, a pathology financial and compliance consulting firm in Simpsonville, Ky. CMS clarifies the ICD-9 code reporting requirements for labs with the following instructions: Pathologist Assigns Most-Definitive Diagnosis What about pathology physician services? "Don't let CMS memos B-03-045 and -046 confuse you," Padget says. "If you're billing for Part B physician pathology services, you should continue to report the ICD-9 code assigned by the pathologist." This is true whether you're billing the professional (with modifier -26, Professional component), technical component (with modifier -TC, Technical component) or global service. If the pathologist reports a definitive diagnosis for an anatomic pathology specimen, you should code and report that diagnosis on your claim, according to Medicare instructions in program memorandum AB-01-144. Not all anatomic specimens demonstrate a pathologic abnormality, however, such as normal colonic mucosa or a negative urine cytology smear. "In such instances, you should bill the physician pathology service using the sign or symptom ICD-9 code - report why the specimen was sent, not what was wrong with it," Padget says.
"CMS emphasizes that you should report ICD-9 codes to 'the highest degree of accuracy and completeness,' meaning that you must precisely match the code to narrative diagnosis and code to the fourth or fifth digit when required," Padget says. "The lab may have to contact the ordering physician for more information to attain the necessary degree of specificity."
"Labs have always been caught in the middle because they had to report a diagnosis with a claim, yet they couldn't assign the diagnosis," says Stan Werner, MT (ASCP), administrative director of Peterson Clinical Laboratory in Manhattan, Kan.
"Medicare's latest instructions provide good direction for labs - get the ICD-9 from the ordering physician, or failing that, get the narrative diagnosis," Werner says. "If the ordering physician doesn't supply either, you'll have to call and get the information; you can't submit a claim without an ICD-9." You should get it in writing, because you must have documentation to support the code.
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