Pathology/Lab Coding Alert

Unbundling breaking down a single procedure into its component parts and billing for additional services is a major compliance problem. Unfortunately, many physicians dont understand this concept, which can lead to claim denials. By reviewing the basic ideas behind bundling, such as component and comprehensive codes, pathologists can avoid such problems.

By far the largest source of bundling combinations, or edits, is Medicares national Correct Coding Initiative (CCI), which has developed coding policies and more than 120,000 edits for reimbursement compliance to better control improper coding.

Although the CCI has been in place since Jan. 1, 1996, many pathologists still do not understand its impact on how they bill procedures. This has serious compliance consequences because Medicare auditors may construe billing for procedures bundled into others as fraud.

Mutually Exclusive Codes

The CCI is particularly important to pathologists because the billing for many of the procedures they perform is guided by its policies. Approximately 11,000, or just less than 10 percent, of the CCIs 120,000 edits are categorized as mutually exclusive. These code pairs describe tests that would not reasonably be performed for the same patient by the same physician on the same day.

For example, blood counts that measure similar parameters but use different laboratory methodology would not be conducted together. That is why 85023 (blood count; hemogram and platelet count, automated, and manual differential WBC count [CBC]) should not be reported with 85025 (blood count; hemogram and platelet count, automated, and automated complete differential WBC count [CBC]). The code that most accurately describes the methodology used should be reported. Mutually exclusive codes are not considered bundled, but they do represent codes that should not be reported together.

Component and Comprehensive Codes

Most CCI edits, about 90 percent of them, may be categorized roughly as bundles comprehensive codes that include component codes. Physicians may not bill the component codes if they also charge for the comprehensive procedure.

For example, the service for code 88329 (pathology consultation during surgery) is included in the service for 88331 (pathology consultation during surgery; with frozen section[s], single specimen). Listing both 88329 and 88331 for a single consultation with frozen section would be considered unbundling of services.

CCI further subdivides the comprehensive/component code category according to principles used to determine the edit. These principles include:

1. CPT Definition. Some CPT Codes are part of a series in which the first code becomes a component for the codes that follow it because they refer back to the common portion of the [...]