Pathology/Lab Coding Alert

Heed consult rules and dodge 80500 payment woes

Keep your eye on the difference between lab oversight and lab consultation, and you can reap a $20 reward. That's roughly what Medicare pays for a pathologist's professional consultation on an abnormal lab test.

Don't Let -Oversight- Rule Mislead You

You can't bill a consultation fee for a pathologist's direction, supervision and other oversight services in the laboratory. But if your pathologist consults on a specific lab test, you may be able to claim your legitimate pay.

Use 80500 (Clinical pathology consultation; limited, without review of patient's history and medical records) or 80502 (- comprehensive, for a complex diagnostic problem, with review of patient's history and medical records) to report the consultation service--but only if the circumstances fulfill the requirements discussed in -Avoid Missteps With Clinical Lab Professional Services--Here's How- included within this issue.

Legitimately Clear CCI Payment Hurdle

Medicare's national Correct Coding Initiative (CCI) throws coders a curve ball by bundling 80500 and 80502 with hundreds of lab tests. That doesn't mean you can never report one of the two codes with a lab test code. Situations arise that involve ambiguous or conflicting test results, and the attending physician may call on the pathologist to help sort things out. That means you can most likely bill a viable clinical consult charge in this case, despite the CCI edit.

CCI bundles 80500 and 80502 with the following codes:

- all 20 lab tests approved by Medicare for pathologist interpretation of clinical lab tests
- some lab panels, such as 80061 (Lipid panel)
- evocative/suppression testing (80400-80440)
- select chemistry codes, such as blood gases (82800-82820), lipids and triglycerides (83700-83721, 84478), and molecular diagnostics (83890-83914)
- many hematology and coagulation codes (85170-85732)
- numerous immunology codes, including flow cytometry total cell counts for immunodeficiency testing (86355-86367)
- certain microbiology codes, including infectious agent antigen detection by immunofluorescent technique (87260-87300), nucleic-acid probes (87470-87801) and immunoassay with direct optical observation (87802-87899)
- many cytogenetic studies, including in situ hybridization (ISH) (88271-88275).

-Notwithstanding the CCI edits, you can bill a professional fee for a consultation related to a clinical lab test when the pathologist provides and documents the service according to the criteria outlined in the Medicare Claims Processing Manual section 60 D,- says Dennis Padget, MBA, CPA, FHFMA, president of DLPadget Enterprises Inc., a pathology business practices company in Simpsonville, Ky., publisher of Pathology Service Coding Handbook.

But these edit pairs are a constant reminder that Medicare expects clinical consult charges by pathologists to be very few in number, Padget says.

Don't miss: Labs must be aware of these CCI edits and code accordingly. The edits impact independent laboratories more than hospital labs because hospitals deal with two Medicare billing entities, Padget says.

Because the hospital bills Part A for the clinical lab test, such as a lipid panel (80061), while the pathologist bills Part B for the 80500 or 80502 consultation, you don't need any special coding rules to report these two services together. -The pathologist doesn't need to append modifier 59 (Distinct procedural service) to 80500 or 80502 in this situation,- Padget says.

On the other hand, independent laboratories must pay attention to the 80500 and 80502 bundling edits. -Independent labs bill Medicare Part B for both the lab test and the consultation in conjunction with non-hospital patients,- Padget says.

Do this: Independent labs that bill an 80500 or 80502 consult with a bundled clinical lab test must use modifier 59 to override the CCI edit pair.

Note: Want to know more? This article and -Avoid Missteps With Clinical Lab Professional Services--Here's How- are adaptations from a presentation at The Coding Institute-s Pathology and Clinical Laboratory Conference 2007 held in Orlando, Fla., Sept. 9-11. Look for CD-ROM and document resources from the conference when they become available soon at www.codingconferences.com/conf_topics.htm.