Pathology/Lab Coding Alert

Your labs serum iron revenues could be anemic if insurers dont know that the patients diagnosis warrants the procedure. When it comes to getting paid for iron tests, the ICD9 Codes is just as important as the CPT code.

Whether suspecting too much or too little serum iron, the physician must tell the lab what signs, symptoms or conditions prompted an iron-test request. Medicare has made that task easier by issuing a National Coverage Determination (NCD) for serum iron studies that sets consistent standards for reporting these codes. You can access the NCD on the Internet at http://www.cms.gov/ncd/labindexlist.asp.

Labs can facilitate correct diagnosis coding by educating physicians about serum iron medical-necessity requirements and designing requisition forms to capture that information. "Labs must know that medical-necessity criteria and some frequency limitations apply to several iron studies, including ferritin (82728), iron (83540) and either iron binding capacity (83550) or transferrin (84466) so they can secure a signed advance beneficiary notice (ABN) when a payable diagnosis is absent," says Joyce Ludwick, clinical laboratory compliance consultant with Park City Solutions Laboratory Services Group in Ann Arbor, Mich.

"Diagnosing anemia, iron deficiency or iron overload conditions relies on tests for iron, ferritin, and either transferrin or iron binding capacity," says Stan Werner, MT (ASCP), administrative director of Peterson Clinical Laboratory in Manhattan, Kan. You need to understand the purpose of each test to correctly report the services. See the inset for a list of serum iron CPT codes and to learn what each test measures.

Physicians must justify use of these serum iron tests by reporting signs and symptoms that indicate medical necessity, according to the NCD. For instance, the following presenting conditions may indicate iron deficiency and support medical necessity for serum iron studies such as ferritin (82728) and transferrin (84466):

Certain abnormal blood tests, for example 790.01 (Precipitous drop in hematocrit)

Acute or chronic gastrointestinal blood loss, such as 531.xx-534.xx (Gastrointestinal ulcers)

Menorrhagia, for instance 627.0 (Premenopausal menorrhagia)

Malabsorption, such as 579.x (Intestinal malabsorption)

Status post-gastrectomy, for example V15.2 (Personal history of surgery to other major organs presenting hazards to health)

Malnutrition, for instance 263.x (Other and unspecified protein-calorie malnutrition)

Malignancies, including many ICD-9 codes from the neoplasms section.

For suspected iron overload conditions, the following illustrate some conditions and ICD-9 codes that may indicate medical necessity for serum iron studies such as iron (83540) and iron binding capacity (83550), according to the NCD:

Liver disease, for example 571.4x (Chronic hepatitis)

Diabetes, for instance 250.xx (Diabetes mellitus)

Arthropathy, such as 716.4x (Transient arthropathy)

Hypopituitarism, for example 253.2 (Panhypopitu-itarism)

Impaired porphyrin metabolism, such as 277.1 (Disorders of porphyrin metabolism)

Thalassemia, for instance 282.4 (Thalassemias)

Cardiomyopathy, for example 425.4 (Other primary cardiomyopathies).

Depending on the clinical situation, Medicare will cover serum iron tests only in certain combinations and at specific frequencies, according to the NCD. "You need to be aware of CMS restrictions to ensure your labs payment for these tests," Ludwick says. Some of the NCD coverage limitations are as follows:

Because transferrin (84466) and iron binding capacity (83550) measurements are essentially the same, Medicare does not cover both tests at the same time.

Following an iron deficiency or overload diagnosis, you may monitor the patients status with either ferritin (82728) or serum iron (83540) plus iron binding capacity (83550) (or transferrin, 84466), but not both.

Medicare does not cover serum iron studies ordered for screening or to "rule out" iron deficiency or overload conditions. Denied ICD-9 codes include V78.0-V78.9 (Special screening for disorders of blood and blood-forming organs).

Medicare does not cover repeat ferritin tests following normal test results unless the patients condition changes and requires ferritin testing for ongoing management. The NCD gives the following illustration: "For example, a patient presents with new onset insulin-dependent diabetes mellitus and has a serum ferritin level performed for the suspicion of hemochro-matosis. If the ferritin level is normal, the repeat ferritin for diabetes mellitus would not be medically necessary."

Medicare approves ferritin testing only once every three months for end-stage renal disease patients, as explained in section 3167.3 of the Fiscal Intermediary Manual.