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Pathology/Lab Coding Alert

Think You'll See $13.52 for Each Stool Isolate?

Published on Fri Mar 26, 2004

Think again: you can no longer code per plate

The 2004 Clinical Laboratory Fee Schedule (CLFS) looks promising for stool culture -- the CPT 87046 national limit payment increased from $3.36 in 2003 to $13.52. But the old payment was for each additional culture, while the new payment is for one or many additional plates -- based on CPT 2004's new code definition
 
Warning: Because CPT 2004 removes "each plate" from the code definition for additional stool isolates, you should report 87046 (Culture, bacterial; stool, aerobic, additional pathogens, isolation and presumptive identification of isolates) once regardless of the number of additional plates. Under the old code definition, you would have reported 87046 for each additional plate.

"If the lab only plates for one additional organism, such as E. coli 0157, you'd report one unit of 87046," says William Dettwyler, MT-AMT, president of Codus Medicus, a laboratory coding consulting firm in Salem, Ore. At the CLFS national limit, that means Medicare would pay $13.52 for one plate (or many) as opposed to $3.36 for one plate under last year's code definition and fee schedule.

But if the lab performs more than one plate, the payment now remains constant at $13.52. "If the lab performs four additional tests for Campylobacter, Yersinia, Vibrio, and E. coli 0157, you'd still report only one unit of 87046," Dettwyler says. Whether one plate or four, Medicare pays $13.52 for 87046. For the same four cultures under last year's code definition and fee schedule, you would have reported four units of 87046 at the national limit rate of $3.36 for a total of $13.44.

Notice that some regions of the country, even now, pay far less for 87046 than the national cap. For example, Virginia pays $5.01 for 87046 in 2004.

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