Pathology/Lab Coding Alert

Medicare Adds Hematology and Consultation Edits


If you report hematology or "consultation on referred material" procedures for your lab, get ready to learn when you can and can't use a modifier to get paid for multiple services. National Correct Coding Initiative (NCCI) edits, version 9.2, effective July1, both open and close some coding loopholes for reporting newly bundled services. 

You Can Report Bundled Codes Together Sometimes

 Medicare pairs procedures into NCCI Edits to indicate that the services are either bundled or not normally performed together. "If a physician carries out two medically necessary, distinct services of an NCCI code pair, Medicare may pay for both procedures if you report them with the appropriate modifier," says William Dettwyler, MT-AMT, coding analyst for Health Systems Concepts, a laboratory coding and compliance consulting firm in Longwood, Fla. 
 
"To indicate that codes represent separate services as opposed to unbundling, append modifier -59 (Distinct procedural service) to override the edit," Dettwyler says. For clinical lab tests conducted more than once a day, use modifier -91 (Repeat clinical diagnostic laboratory test). You can only override an NCCI edit with a modifier if the code pair shows a "1" in the modifier indicator column. A "0" modifier indicator means that you cannot override the edit pair.

Hematology Includes Second Look

 When automated blood counts return results that require the lab to look more carefully at the blood smear or differential, can you report that "second look"? Medicare made it clear in NCCI edits prior to 9.2 that you cannot report a manual differential (85007, Blood count; blood smear, microscopic examination with manual differential WBC count) with a complete CBC and automated differential (85025, Blood count; complete [CBC], automated [Hgb, Hct, RBC, WBC and platelet count] and automated differential WBC count). In other words, if your automated CBC and differential reflexes to a manual diff, you can't report the second differential as an additional service.

 "Medicare's stance is that you have to perform the second differential to accomplish what the doctor ordered it's part of the 85025 service," Dettwyler says.
 
Following the same logic, Medicare added new edit pairs in NCCI 9.2 that disallow reporting a more in-depth (microscopic) exam of the blood smear as a separate hematology service. Medicare now pairs 85008 (Blood count; blood smear, microscopic examination without manual differential WBC count) with the following hematology codes:
 

Learn Referred-Material Consultation Bundles

CPT provides three codes for pathology 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). NCCI 9.2 pairs these consultations with a host of cytopathology and histopathology services. (See "Know How to Override NCCI 9.3 Consultation Bundles" for a complete list of the codes.)
 
Medicare evidently intended these edit pairs to prohibit billing for both the consultation and the original pathology service. For example, if you receive referred slides from a breast lesion excision, you should report only 88321 for the consultation. You should not additionally report the original excision examination (88307, Level V Surgical pathology, gross and microscopic examination, breast, excision of lesion, requiring microscopic evaluation of surgical margins) for the same set of slides.
 
Occasionally, however, a pathologist may perform a referred-material consult and a separate surgical pathology or cytopathology service on a different specimen for the same patient on the same day.
 
"If the pathologist performs an examination of a partial colon resection for cancer and a review of referred slides from an earlier colon biopsy, you should report both services," says Beverly Bloedow, coding resource specialist for Hospital Pathology Associates in Minneapolis, which provides pathology services to Allina Hospitals throughout Minnesota and Wisconsin. Report the colon resection examination as 88309 (Level VI Surgical pathology, gross and microscopic examination, colon, segmental resection for tumor) and the slide consultation as 88321. "Append modifier -59 to indicate that the pathologist performed two distinct services rather than unbundling a single service," Bloedow says.
 
Probably the biggest problem you'll see with these edit pairs is the bundling of consultation on referred material (88323) with special stains (88312-88314) as well as immunocytochemistry (88342) and immunofluorescent antibody studies (88346). "Because 88323 requires slide preparation, it wouldn't be at all unusual to prepare and interpret special stains or studies on the material," Bloedow says. In such situations, you'd need to report both 88323 and the appropriate special stain code with modifier -59 to override the edit pair.
 
"You should not report the special stain codes with an 88321 consultation that includes special stain slides, however, because your lab did not perform the special stain," Bloedow says.

Edits Bundle Different Cytopathology Sources

According to NCCI 9.2, you can no longer report cytopathology services for fluids, washings and brushings (88104-88107) with most cytopathology services for "other" sources (88160-88162) without a modifier. Although intended to prevent double-billing for the same cytopathology specimen, the edit pairs could cause a problem if your lab examines two different cytopathology specimens from the same patient on the same day.
 
For instance, the lab might examine a bronchial brushing (88104, Cytopathology, fluids, washings or brushings, except cervical or vaginal; smears with interpretation) and a lung biopsy touch prep (88161, Cytopathology, smears, any other source; preparation, screening and interpretation) on the same day. With the new edit pairs, you'll have to report these services with modifier -59 if you want to get paid for both procedures.