Pathology/Lab Coding Alert

Rules limit new molecular diagnostics and consultation codes, too

If your lab performs infectious agent detection tests for strep (87653) or staph (87640, 87641) or other organisms bearing new CPT 2007 codes, prepare to maneuver many National Correct Coding Initiative edit pairs. You need to know the new codes -- and the bundling rules -- if you want to get paid for your services.

The NCCI, version 13.0, took effect Jan. 1. You can access the edits online at www.cms.hhs.gov/physicians/cciedits/default.asp.

Start Using Organism-Specific Codes

CPT provides method-specific infectious agent detection codes for organisms that are -not otherwise specified.- But you should stop using those codes (87798, Infectious agent detection by nucleic acid [DNA or RNA], not otherwise specified; amplified probe technique, each organism; 87449, Infectious agent antigen detection by enzyme immunoassay technique, qualitative or semiquantitative; multiple-step method, not otherwise specified, each organism; and 87899, Infectious agent detection by immunoassay with direct optical observation; not otherwise specified) for the following organisms/methods that have new CPT codes in 2007:

- 87305 -- Infectious agent antigen detection by enzyme immunoassay technique, qualitative or semiquantitative, multiple-step method; Aspergillus

- 87498 -- Infectious agent detection by nucleic acid (DNA or RNA); enterovirus, amplified probe technique

- 87640 -- Infectious agent detection by nucleic acid (DNA or RNA); Staphylococcus aureus, amplified probe technique

- 87641 -- Infectious agent detection by nucleic acid (DNA or RNA); Staphylococcus aureus, methicillin resistant, amplified probe technique

- 87653 -- Infectious agent detection by nucleic acid (DNA or RNA); Streptococcus, group B, amplified probe technique

- 87808 -- Infectious agent antigen detection by immunoassay with direct optical observation; Trichomonas vaginalis.

Don't Bill Twice for a Single Method

Think you can bill for antigen detection by nucleic acid probe and separately code for direct or amplified probe techniques? Think again. NCCI 13.0 bundles new codes 87498, 87640, 87641 and 87653 with both 87149 (Culture, typing; identification by nucleic acid probe) and 87801 (Infectious agent detection by nucleic acid [DNA or RNA], multiple organisms; amplified probe[s] technique).

Reason: -Infectious agent antigen detection codes in the CPT microbiology section are for tests performed on a primary source, such as serum or stool specimen, and describe both the lab method used and the organism identified,- says Larry Small, MS, MT (ASCP), principal consultant with L. Small Associates, a clinical laboratory and anatomic pathology compliance operations and billing specialty company. -For a single test, you should select the single code that most precisely describes these two elements.-

Exception: -If the lab performs two separate tests from two separate sources, you can report the appropriate CPT code for each test,- Small says.

For example, if the lab tests a throat swab for Streptococcus, group B by amplified probe technique (87653) and also types an isolate cultured from the patient's skin using nucleic acid probe (87149), you can report both codes.  

Tip: Now that NCCI bundles these two codes, you-ll have to use modifier 59 (Distinct procedural service) to override the edits when the lab performs the tests on two distinct specimen sources.

Don't Bill Twice for a Single Organism
 
How about billing different codes for enterovirus identification together, such as new code 87498 with 87267 (... Enterovirus, direct fluorescent antibody [DFA])?  NCCI says you can't bill these together, which reflects correct coding principles. You have to pick a single enterovirus detection code based on the lab technique.

NCCI 13.0 adds similar edit pairs for the other new organism-specific codes:

Don't report 87653 with 87802 (Infectious agent antigen detection by immunoassay with direct optical observation; Streptococcus, group B) for a single test.

Choose 87808 or 87660 (... Trichomonas vaginalis, direct probe technique) for a test based on lab technique.

Because methicillin-resistant Staphylococcus aureus is a specific strain, NCCI also bundles 87640 and 87641 -- choose the most specific code for your test.

The bottom line: -Labs have many methods available to detect an infectious agent, but they only use one specific method for any given test,- Small says. The coding question is -- which method did the lab use? For identification of a single organism, you-ll have to assign the correct CPT code based on the lab method.

Include Molecular Diagnostics Steps

Some of the steps that labs use for infectious-agent detection by nucleic acid are similar to the procedures described by the molecular diagnostics codes (83890-83913). These include processes such as nucleic acid extraction (83891) and amplification (83898). The molecular diagnostic codes correctly describe these step-wise lab procedures for genetic studies.

-Coders might think they can report these molecular steps along with the infectious agent detection code, but that is incorrect and amounts to unbundling,- says Elizabeth Sheppard, HT (ASCP), marketing manager for Ventana Medical Systems in Tucson, Ariz. -The infectious agent codes include all procedures required to identify the organism.-

That's why NCCI 13.0 bundles each new code for infectious agent detection by nucleic acid (87498, 87640, 87641, and 87653) with each of the molecular diagnostics codes (83890-83913).

Don't miss: Because 83913 (Molecular diagnostics; RNA stabilization) is new in CPT 2007, the latest version of NCCI also adds edit pairs for 83913 with all other codes for infectious agent by probe technique (87470-87801 and 87149) as well as codes for infectious agent genotype/phenotype analysis (87901-87903).

Avoid Consultation Bundles

NCCI 13.0 bundles the new infectious agent (87498, 87640, 87641, 87653, 87808) and molecular diagnostics (83913) codes 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 patient's history and medical records).

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.