Pathology/Lab Coding Alert

Hint: You'll have to distinguish 80500 and 88321 code families

If you ever bill molecular diagnostics (MD) tests with pathology consults--watch out. National Correct Coding Initiative (NCCI) version 13.1 bundles certain MD codes with consultation codes 80500-80502 and 88321-88325.

They-re Here--New Consult Edit Pairs

The latest NCCI version bundles 80500 (Clinical pathology consultation; limited, without review of patient's history and medical records) and 80502 (... comprehensive, for a complex diagnostic problem, with review of patient's history and medical records) with these codes:

- 83900--Molecular diagnostics; amplification of patient nucleic acid, multiplex, first two nucleic acid sequences
- 83907--... lysis of cells prior to nucleic acid extraction (e.g., stool specimens, paraffin embedded tissue)
- 83908--... signal amplification of patient nucleic acid, each nucleic acid sequence
- 83914--Mutation identification by enzymatic ligation or primer extension, single segment, each segment (e.g., oligonucleotide ligation assay [OLA], single base chain extension [SBCE], or allele-specific primer extension [ASPE])
- 88384--Array-based evaluation of multiple molecular probes; 11 through 50 probes
- 88385--- 51 through 250 probes
- 88386--- 251-500 probes.

You-ll also find that NCCI bundles molecular diagnostics array codes 88384-88386 with codes for consultation on referred material: 88321 (Consultation and report on referred slides prepared elsewhere), 88323 (Consultation and report on referred material requiring preparation of slides), and 88325 (Consultation, comprehensive, with review of records and specimens, with report on referred material).

Prior to version 13.1, NCCI bundled other molecular diagnostics codes from 83890-83913 with the 80500 and 80502 consult codes.

Identify the 3 R's and More for Consultation Codes

All consultations require the 3 R-s--request (from treating physician), render (medical opinion) and report (findings). But that's not all you need to know to choose the proper consultation code for you pathologist's service.

Study the following pathology consultation refresher to understand the differences in the consult codes and when you can--or can-t--override the new edit pairs.

Know Clinical Pathology Consultation Rules

You should select one of the clinical pathology consultation codes (80500 or 80502) when the service meets the following criteria, in addition to the 3 R-s:

- the consultation is for a clinical lab test result
- the consultation follows an abnormal test finding.
 
The breadth of the assessment distinguishes the two codes, with 80502 reserved for cases requiring the pathologist's full review of patient history and records.

Only report the clinical pathology consultation when you meet the following criteria, according to Section 15020-D of the Medicare Carriers Manual:

- The patient's attending physician orders the consultation, not just the underlying lab test. Medicare specifies that standing orders do not satisfy this request requirement.
- The consultant must issue a written report.
- The consultation requires the consulting physician to exercise medical judgment.
- The lab test result behind the consultation must lie outside the clinically significant normal or expected range in view of the patient's condition.

-Don't confuse this service with the physician's interpretation of a clinical lab test,- says Kenneth Wolfgang, MT (ASCP), CPC, CPC-H, CEO of Chargemaster Maintenance Services, a laboratory consultation company in Portland, Ore. Medicare has designated 18 lab tests as having a professional interpretation component that it will reimburse under the Physician Fee Schedule. Included are hemoglobin electrophoresis (83020), molecular diagnostics (83912), protein electrophoresis and Western Blot (84165, 84181-84182 and 88371-88372), immunoelectrophoresis (86320-86327), and fluorescent noninfectious agent antibody tests (86255-86256). The MCM section 15020-E contains the complete list.

To report the clinical lab test interpretation, the pathologist must meet the first three criteria listed above for a consultation, except that standing orders will suffice for the request.

-Rather than using 80500 to report interpretation of these tests, the pathologist should bill the service using the appropriate laboratory code with modifier 26 (Professional component),- Wolfgang says.

Medicare's recent bundling of molecular diagnostics codes with 80500 and 80502 adds to the hundreds of code pairs NCCI already has with these consult codes. The edits indicate that you cannot bill Medicare for a pathologist's medical direction and supervision of clinical lab tests under the guise of an 80500 or 80502 consultation.

Do this: But that doesn't mean a pathologist can't charge for an 80500 or 80502 consultation related to lab tests such as molecular diagnostics when he meets and documents the requirements for a consultation. If the attending physician requests a consultation on an abnormal lab test result and the pathologist renders a professional opinion and files a report, you can report 80500 or 80502 with any of the bundled lab codes by appending modifier 59 (Distinct procedural service) to the consultation code.

Consultation on Referred Material Is Different

Three codes describe pathology consultations on slides or tissue referred from an outside institution: 88321, 88323, and 88325.

Like the 80500 family, these codes report ascending levels of consultation complexity. Use 88321 when the pathologist reviews previously prepared slides, and use 88323 when your lab must prepare slides from referred tissue before the pathologist examines them, says R.M. Stainton Jr., MD, president of Doctors- Anatomic Pathology Services in Jonesboro, Ark. As with 80502, report 88325 only when the pathologist reviews the full patient history, such as surgical notes and oncology reports, along with the tissues and slides.

You should use 88321-88325 when the medical record documents the following:

- The consultation request is for a surgical pathology or cytology case from an outside institution.
- The consultation does not occur during surgery but later, following an initial diagnosis.

Caution: -Unlike most other surgical pathology codes, the specimen is not the unit of service for 88321-88325,- Stainton says. Instead, report one unit of 88321 for one accession, which may include multiple specimens from one surgical pathology or cytology case.

-Depending on the date or body area that multiple slides or tissues came from, you might have one or multiple accessions,- Stainton says.

For example: You should report two units of 88321 for consultation on slides from a lesion excision taken on one date and slides from a margin re-excision taken two days later. But you should report only one unit of 88321 for a consultation on slides from a hysterectomy and a separate lymph node resection taken from the same patient on the same day.

When to override NCCI edit: Although NCCI 13.1 bundles referred consultation codes (88321-88325) with microarray codes (88384-88386), you can report the two together under some circumstances.

Don't report the microarray if it was part of the initial testing before the outside source referred the case to your pathologist. The NCCI policy manual states, -Providers should not report other pathology CPT codes such as ... 88342, etc., for interpretation of stains, slides or material previously interpreted by another pathologist.-

Do report the microarray with the consultation code if the consulting pathologist performs an adjunct procedure such as 88384 on tissue submitted for a consultation (88323). You can report both services together using modifier 59.

Caution: You shouldn't code additional tests such as microarray with 88321 because the slides were prepared elsewhere.