Pediatric Coding Alert

This chart helps you get the right 80000 series code for over 20 in-office test brands

Before you're knee-deep in denied rapid strep and urinalysis test claims, take a few minutes to review these in-office laboratory rules.

Use Standard Code Set, HIPAA Says

You can perform some laboratory tests in the office. The CDC or FDA deems certain tests so simple that little risk of error exists. Therefore, a physician may perform the procedures in his office without obtaining a higher-level certificate, says Lorna Powell, CCS-P, owner of Quality Medical Management in Elk City, Okla. "You call these tests waived-status tests."

Waived status is a Clinical Laboratory Improvement Amendments (CLIA) term. The policies "fall under the Medicare and Medicaid umbrella," says Kevin Perryman, practice administrator at Primary Pediatric Medical Association PA in Kerrville, Texas.

Watch out: Just because Medicare oversees CLIA implementation doesn't mean you're exempt from its regulations. "Even though pediatricians don't have Medicare patients, you still have to follow CMS' lab-test coding guidelines," Perryman says.

Why: HIPAA requires that you code consistently. "So we bill in-office tests according to Medicare's rules, which offer a standard to follow," Perryman says.

Submit Flawless Claims in 4 Easy Steps

When your office performs a waived test, code based on these guidelines:

1. Report the appropriate CPT test code.

2. Append the procedure code with modifier -QW (CLIA waived test). "We use modifier -QW on all waived tests, and we've never had any problems receiving in-office lab payment," Perryman says.

3. Link the CPT code to the ICD-9 diagnosis code.

4. Record your CLIA number on the claim form.

Coding example: You perform a rapid strep test on a patient. The test is positive. You diagnosis the patient with strep A and prescribe oral antibiotics.

In this case, you should report the strep test with 87880 (Infectious agent detection by immunoassay with direct optical observation; Streptococcus, group A]), which is the only CLIA-waived strep test made by a number of manufacturers. "Add modifier -QW to the code," Powell says. The modifier indicates that the test is a CLIA-waived test.

But appending modifier -QW isn't enough to complete the claim. "You also have to write your CLIA number in item 23 of the CMS-1500 form," Powell says. If you file the claim electronically using NSF format, enter the number in FA0-34.0.
 
ICD-9 step: Link 87880 to 041.01 (Streptococcus; group A).

Access the Right Lab Code

Not sure which tests you can perform in-office and their corresponding CPT codes? If you have a CLIA waived-status certification, you can bill for performing these simple laboratory tests shown in chart above right.