Pathology/Lab Coding Alert

You can't override '0' modifier indicator

Watch out for new edit pairs you can't override: The National Correct Coding Initiative bundles 85046 for reticulocyte cellular parameters with blood count codes 85045 and 85044.

Because NCCI version 11.2 lists these code pairs with a "0" modifier indicator, you can't override the bundled tests under any circumstances, says Stacey Hall, RHIT, CPC, CCS-P, RCC, director of corporate coding for Medical Management Professionals Inc. in Nashville, Tenn.

Version 11.2 went into effect July 1, and you can access the edits online at www.cms.hhs.gov/physicians/cciedits/default.asp.

Extensive Procedure Includes All

When one test parameter that could stand alone is part of a more comprehensive test, you can't report codes for both tests. Code 85046 (Blood count; reticulocytes, automated, including one or more cellular parameters [e.g., reticulocyte hemoglobin content (CHr), immature reticulocyte fraction (IRF), reticulocyte volume (MRV), RNA content], direct measurement) includes the work of a total reticulocyte count, either manual (85044, Blood count; reticulocyte, manual) or automated (85045, Blood count; reticulocyte, automated). NCCI bundles these codes based on the principle of "more extensive procedures."

According to NCCI, more extensive procedures means that "when procedures performed together ... are qualified by an increased level of complexity, the less extensive procedure is included in the more extensive procedure." So a complex reticulocyte count involving specific cellular parameters (85046) includes the less extensive reticulocyte count (85044 or 85045).

So when your lab determines reticulocyte hemoglobin content (CHr) to assess iron deficiency in a hemodialysis patient, the test includes the total reticulocyte count, and you can't bill 85044 or 85045 in addition to 85046.

The same goes for immature reticulocyte fraction (IRF) used to manage response during bone marrow engraftment, because the test includes the total reticulocyte count, and billing 85046 with 85044 or 85045 would be unbundling.

Another example: NCCI 11.2 also bundles 88275 (Molecular cytogenetics; interphase in situ hybridization, analyze 100-300 cells) with 88274 (Molecular cytogenetics; interphase in situ hybridization, analyze 25-99 cells), because 88275 is the more extensive procedure. "That means you can't report both 88274 and 88275 for a single cytogenetic study involving more than 100 cells," says Peggy Slagle, CPC, billing compliance coordinator at the University of Nebraska Medical Center in Omaha.

Exception: But what if the lab examines interphase cell nuclei from two separate cell cultures to detect different genes or chromosomes? "If one of the molecular cytogenetics studies involves 25-99 cells, and the other involves 100-300 cells, you can report both 88275 and 88274 using modifier 59 (Distinct procedural service)," Slagle says. Because the work involves two separate analyses and NCCI lists codes 88275 and 88274 with a modifier indicator of "1," you can bill for both tests on the same day.

Avoid Clinical Consultation With New Codes

CPT 2005 added three new codes that NCCI now bundles with clinical pathology consultation codes 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 a patient's history and medical records).

The bundled codes are as follows:

84166 - Protein; electrophoretic fractionation and quantitation, other fluids with concentration (e.g., urine, CSF)

86335 - Immunofixation electrophoresis; other fluids with concentration (e.g., urine, CSF)

87807 - Infectious agent antigen detection by immunoassay with direct optical observation; respiratory syncytial virus.

These edit pairs add to the many clinical lab tests that NCCI bundles with 80500 and 80502. 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 a clinical lab test 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 using modifier 59," Slagle says.

Don't miss: Instead of consultation codes 80500 or 80502, you can report a pathologist's interpretation of a few, specific lab tests to Medicare using modifier 26 (Professional component). The Physician Fee Schedule shows which lab codes you can use with modifier 26, and it includes codes 84166 and 86335. The pathologist's interpretation is similar to the consultation, except that a standing order can substitute for a request by the attending physician, and the lab-test result does not have to be outside of the normal range.