Pulmonology Coding Alert

Question: I am having difficulty getting reimbursed for laboratory services provided in the physician's office.


Nebraska Subscriber

Answer: Congress passed the Clinical Laboratory Improvement Amendments (CLIA) in 1988, which mandates the certification of all laboratories that examine specimens derived from the human body for diagnosis, prevention, or treatment purposes. 

CMS in conjunction with the Centers for Disease Control and Prevention and the Food and Drug Administration administer the CLIA laboratory certification program.

Laboratories that have enrolled and received "waived" status can performs tests that the FDA or CDC determines to be so simple that there is little risk of error, according to the CLIA law.

Physician offices should perform only those CLIA-waived tests, regardless of which insurer is receiving the claim. 

Extra: You can obtain a complete list of CLIA-waived tests as well as other information about the program from http://www.cms.hhs.gov/clia/. 

When coding for laboratory services, one of the most frequent errors is reporting the pathology/laboratory code when only a blood draw (for obtaining the specimen) is provided. If the physician is not processing the specimen for analysis, he should only report the most appropriate code to represent the method to obtain the specimen.

If the physician draws blood by arterial puncture, you should report 36600. If the physician places a catheter arterially to spare the patient from multiple "sticks" when multiple samples will be taken, report 36620.  Similarly, if the physician places a catheter into the vein, report 36000.

- Answers for You be the Coder and Reader Questions were reviewed by Carol Pohlig, BSN, RN, CPC, senior coding and education specialist at the University of Pennsylvania department of medicine in Philadelphia; and Alan L. Plummer, MD, professor of medicine, division of pulmonary, allergy and critical care at Emory University School of Medicine in Atlanta.