Coding and Payment Guide for Laboratory Services An essential coding, billing and reimbursement resource for laboratory and pathology services

2013

Contents Introduction ......................................................................1 Coding Systems .................................................................... 1 Claim Forms ......................................................................... 2 Contents and Format of This Guide ...................................... 3 How to Use This Guide ......................................................... 3 The Reimbursement Process .............................................5 Coverage Issues .................................................................... 5 Payer Types .......................................................................... 5 Payment Methodologies ..................................................... 10 Laboratory and Pathology Reimbursement ......................... 12 Calculating Costs ................................................................ 21 Other Factors Influencing Payment ..................................... 21 Participation in Medicare Plans ........................................... 29 Workers’ Compensation ...................................................... 36 Collection Policies ............................................................... 36 Documentation—An Overview .......................................39 Methods of Documentation ................................................ 39 General Guidelines for Documentation ............................... 40 Waste, Fraud, and Abuse .................................................... 41

Medicare Benefit Notices .....................................................56 The CMS-1500 Claim Form ................................................. 60 How to Complete the CMS-1500 Form ............................... 60 The UB-04 Claim Form ........................................................75 Procedure Codes .............................................................83 CPT Coding Conventions .................................................... 83 Unlisted Procedures ............................................................. 84 Modifiers ............................................................................. 84 Codes .................................................................................. 85 CPT Index ......................................................................729 ICD-9-CM Diagnosis Codes ...........................................741 The Structure of ICD-9-CM ...............................................741 The Structure of the Tabular List ........................................741 General Coding Guidelines ................................................743 Medicare Official Regulatory Information ...................745 Glossary ......................................................................... 751

Claims Processing ...........................................................49 What to Include on Claims ................................................. 49 Clean Claims ...................................................................... 50 The Health Insurance Portability and Accountability Act ...... 50 Processing the Claim .......................................................... 53

© 2011 Optum

Appendix A. CLIA Waived Tests ...................................763 Appendix B. Laboratory Fee Schedule .........................805

CPT codes only © 2011 American Medical Association. All Rights Reserved.

i

Coding and Payment Guide for Laboratory Services health. Medicare Part B coverage provides payment for medical supplies, physician, and outpatient services. Not all services rendered by a facility are inpatient services. Providers working in facilities routinely render services on an outpatient basis. Outpatient services are provided in settings that include rehabilitation centers, certified outpatient rehabilitation facilities, SNFs, and hospitals. Outpatient and partial hospitalization facility claims might be submitted on either a CMS-1500 or UB-04, depending on the payer. For professional component billing, most claims are filed using ICD-9-CM diagnosis codes to indicate the reason for the service, CPT codes to identify the service provided, and HCPCS Level II codes to report supplies on the CMS-1500 paper claim or the 837P electronic format. A step-by-step guide for completing the CMS-1500 and UB-04 claim forms and an explanation of the claims filing process can be found in the claims processing section of this Coding and Payment Guide.

Contents and Format of This Guide The first three chapters following this introduction provide information regarding the reimbursement process, documentation, and claim completion, respectively. The fifth chapter, “Procedure Codes for Laboratory Services,” contains a numeric listing of procedure codes. Each page identifies the information associated with that procedure including an explanation of the service, coding tips, associated diagnoses, related terms, CMS internet-only manual references that identify any official references found in the Medicare Online Manual System. The full excerpt from the online CMS Manual System pertaining to the reference is provided in the Medicare official regulatory information chapter. The procedure code pages also have a list of codes from the official Centers for Medicare and Medicaid Services National Correct Coding Policy Manual for Part B Medicare Contractors that are considered to be an integral part of the comprehensive or mutually exclusive procedures and should not be reported separately. Finally, all relative value information relevant to the code is listed at the bottom of the page. Following this chapter you will find a procedure code index and an index for HCPCS Level II codes for radiology services.

Introduction Some CPT codes are omitted from the listing because consistent and reliable cross-links are almost impossible to establish. Unlisted procedures are an obvious example. Certain types of add-on codes also are treated somewhat differently. The laboratory cross coder information presents the most likely scenarios as derived from clinical information sources and federal national coverage determinations (NCD). However, the laboratory cross coder information is not a substitute for ICD-9-CM, or any other medical coding reference, and users are urged to regularly consult all available sources. The absence of any specific code does not necessarily indicate that its association to the base procedure is inappropriate. Likewise, the inclusion of a code does not guarantee coverage.

How to Use This Guide The first three chapters: “The Reimbursement Process,” “Documentation—An Overview,” and “Claims Processing” may be read in their entirety and/or used as references. When using this Coding and Payment Guide for code assignment, follow these important steps to improve accuracy and experience fewer overlooked diagnoses and services: •

Step 1. Carefully read the medical record documentation that describes the patient’s diagnosis and the service provided. Remember, more than one diagnosis or service may be documented.

•

Step 2. Locate the main term for the procedure or service documented in the CPT index. This will identify the procedure code that may be used to report this service.

•

Step 3. Locate the procedure code in the chapter titled “Procedure Codes.” Read the explanation and determine if that is the procedure performed and supported by the medical record documentation. The Terms to Know section may be used ensure appropriate code assignment.

•

Step 4. At this time you can review the additional information pertinent to the specific code found in the coding tips, IOM reference, and CCI sections or the Medicare physician fee schedule references.

•

Step 5. Peruse the list of ICD-9-CM codes to determine if the condition documented in the medical record is listed and the code identified. If the condition is not listed refer to the ICD-9-CM index or your ICD-9-CM manual to locate the appropriate code. At this time, you may also determine what, if any, CCI edits are applicable.

•

Step. 6. Determine if any Medicare regulatory information is associated with this code and if so, an excerpt of this information may be found in the appendix titled, “Medicare Official Regulatory Information.”

•

Step 7. Finally, review the HCPCS Level II section to determine if there are applicable HCPCS Level II codes that may be reported. This section also includes HCPCS Level II modifiers as well as coding tips.

Glossary and CLIA-Waived Tests The final section consists of: •

A glossary of coding, billing and, clinical terms applicable to laboratory and pathology

•

A listing of the tests granted waived status under the Clinical Laboratory Improvements Amendment (CLIA)

Laboratory Cross-Coder In addition you will find with this book a CD containing up-to-date CPT laboratory codes linked to the ICD-9-CM and HCPCS coding systems.

© 2011 Optum

CPT codes only © 2011 American Medical Association. All Rights Reserved.

3

Procedure Codes

Coding and Payment Guide for Laboratory Services

80061 - NCD 80061

250.41

Lipid panel

250.70

Explanation A lipid panel includes the following tests: total serum cholesterol (82465), high-density cholesterol (HDL cholesterol) by direct measurement (83718), and triglycerides (84478). Blood specimen is obtained by venipuncture. See specific codes for additional information about the listed tests.

Coding Tips

Terms To Know cholesterolemia. Elevated levels of cholesterol in the blood that may be an inherited disorder or caused by certain environmental factors. Report this condition with ICD-9-CM code 272.0. CLIA. Clinical Laboratory Improvement Amendments. Requirements set in 1988, CLIA imposes varying levels of federal regulations on clinical procedures. Few laboratories, including those in physician offices, are exempt. Adopted by Medicare and Medicaid, CLIA regulations redefine laboratory testing in regard to laboratory certification and accreditation, proficiency testing, quality assurance, personnel standards, and program administration. specimen. Tissue cells or sample of fluid taken for analysis, pathologic examination, and diagnosis. venipuncture. Piercing a vein through the skin by a needle and syringe or sharp-ended cannula or catheter to draw blood, start an intravenous infusion, instill medication, or inject another substance such as radiopaque dye.

ICD-9-CM Diagnostic Codes 250.01 250.02 250.03 250.40

Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled Diabetes mellitus without mention of complication, type I [juvenile type], not stated as uncontrolled Diabetes mellitus without mention of complication, type II or unspecified type, uncontrolled Diabetes mellitus without mention of complication, type I [juvenile type], uncontrolled Diabetes with renal manifestations, type II or unspecified type, not stated as uncontrolled — (Use additional code to identify manifestation: 581.81, 583.81, 585.1-585.9) Work Value

80061........................ 0.00

100

272.0 272.2

A national coverage determination (NCD) exists for this code. See Medicare National Coverage Determinations Manual, Pub.100-03, section 190.23. This test may be performed using a CLIA-waived test system. Laboratories with a CLIA-waived certificate must report this code with modifier QW CLIA-waived test. According to CPT guidelines, do not report two or more organ or disease-oriented panels when any of the same tests are performed in each panel and the panels are performed from the same patient collection. When a group of tests overlap two or more panels, report the panel that has the greatest number of tests allowing the definition of that panel to be met and than report the remaining tests using the appropriate individual test codes.

250.00

250.71

272.8 278.01

278.02

401.9 402.00 402.01

402.10 414.05

414.06

414.3 414.8

Diabetes with renal manifestations, type I [juvenile type], not stated as uncontrolled — (Use additional code to identify manifestation: 581.81, 583.81, 585.1-585.9) Diabetes with peripheral circulatory disorders, type II or unspecified type, not stated as uncontrolled — (Use additional code to identify manifestation: 443.81, 785.4) Diabetes with peripheral circulatory disorders, type I [juvenile type], not stated as uncontrolled — (Use additional code to identify manifestation: 443.81, 785.4) Pure hypercholesterolemia — (Use additional code to identify any associated intellectual disabilities) Mixed hyperlipidemia — (Use additional code to identify any associated intellectual disabilities) Other disorders of lipoid metabolism — (Use additional code to identify any associated intellectual disabilities) Morbid obesity — (Use additional code to identify Body Mass Index (BMI), if known: V85.0-V85.54) (Use additional code to identify any associated intellectual disabilities) Overweight — (Use additional code to identify Body Mass Index (BMI), if known: V85.0-V85.54) (Use additional code to identify any associated intellectual disabilities) Unspecified essential hypertension Malignant hypertensive heart disease without heart failure Malignant hypertensive heart disease with heart failure — (Use additional code to specify type of heart failure, 428.0-428.43, if known) Benign hypertensive heart disease without heart failure Coronary atherosclerosis of unspecified type of bypass graft — (Use additional code to identify presence of hypertension: 401.0-405.9) Coronary atherosclerosis, of native coronary artery of transplanted heart — (Use additional code to identify presence of hypertension: 401.0-405.9) Coronary atherosclerosis due to lipid rich plaque — (Code first coronary atherosclerosis (414.00-414.07)) Other specified forms of chronic ischemic heart disease — (Use additional code to identify presence of hypertension: 401.0-405.9)

This list of ICD-9-CM codes might not be all-inclusive. Please refer to your Laboratory Cross Coder to determine if other diagnoses are applicable.

IOM References 100-3,190.23; 100-4,16,70.8

CCI Version 17.3 80500-80502, 82465, 83718, 83721, 84478 Note: These CCI edits are used for Medicare. Other payers may reimburse on codes listed above.

Non-Fac PE

Fac PE

Malpractice

Non-Fac Total

Fac Total

0.00

0.00

0.00

0.00

0.00

CPT only © 2011 American Medical Association. All Rights Reserved.

© 2011 Optum

Procedure Codes

Coding and Payment Guide for Laboratory Services

80173

80201

Explanation

Explanation

This drug, also known as Haldol, is a well-established tranquilizer with antipsychotic and other properties. Blood concentrations of haloperidol do not correspond well with therapeutic dosages; therefore, assays may be performed to establish compliance or to measure the body's ability to metabolize the drug. Methods may include high performance liquid chromatography (HPLC), gas liquid chromatography (GLC), and radioimmunoassay (RIA).

This drug may also be known as Topamax. It is currently classified as an orphan drug, a designation for certain drugs and biologicals used principally for very rare diseases. The product is kept in supply only in limited quantities for the limited number of patients requiring therapy. Distribution is not general. This particular drug is used primarily in the treatment of Lennox-Gastaut syndrome.

80173

80201

Haloperidol

80195 80195

Sirolimus

Explanation This procedure tests for the level of sirolimus (rapamycin), a potent immunosuppressant in the blood. Sirolimus blood levels may be affected by cytochrome P450 3A4 inducers or inhibitors or by patient liver function (hepatic insufficiency). Therapeutic drug monitoring (TDM) of sirolimus concentrations are frequently performed to monitor blood concentration levels and evaluate dosage.

Topiramate

80416-80417 80416

Renal vein renin stimulation panel (eg, captopril)

80417

Peripheral vein renin stimulation panel (eg, captopril)

Explanation

80196

These tests may be ordered as renin "Stim" panel, renin activity panel, or plasma renin activity (PRA) panel. Baseline samples may be drawn from the renal vein (80416) or peripheral vein (80417) and tested for renin. Renin is an enzyme synthesized in the kidney. A renin-stimulating agent, such as the diuretics captopril and furosemide, is administered, usually orally and usually in several stages. The patient remains upright for several hours before again testing for renin, once again, usually in stages. The panel is a useful screen and diagnostic tool for various forms of hypertension, renal artery disorders, and other disorders of the renal/circulatory system.

Explanation

80432

80196

Salicylate

This drug is known universally as aspirin and may also be referred to as a nonsteroidal antiinflammatory drug (NSAID). Specimen collection is at trough, which is the time just before the next dose of the drug when blood concentration is at its lowest. Overdose may also prompt this test. Methodology may include high performance liquid chromatography (HPLC) or gas liquid chromatography (GLC). Colorimetry and fluorometry may also be used.

80197 80197

Tacrolimus

Explanation This drug is also known as Prograf. It is an immunosuppressant and may be prescribed for a number of conditions, including post-transplant therapies. Blood concentration monitoring may be ordered with this drug, particularly when delivered by IV. In this event, specimen collection may be random. Methodology may include high performance liquid chromatography (HPLC).

Insulin-induced C-peptide suppression panel

Explanation This panel may be ordered as connecting peptide insulin, insulin C-peptide, or proinsulin C-peptide. C-peptide is formed in the islets of Langerhans in the pancreas along with insulin. Both are released into the portal vein. C-peptide levels generally correlate to insulin levels and may reflect pancreatic function. Blood work is usually performed prior to the test to establish a baseline. Insulin is injected intravenously and blood is drawn at intervals for C-peptide and glucose; insulin is tested for only once.

80434-80435 80434 80435

Insulin tolerance panel; for ACTH insufficiency for growth hormone deficiency

Explanation The insulin tolerance panel for ACTH insufficiency typically involves baseline blood work before testing. The insulin is administered following a fasting period, typically by an indwelling needle. The panel is specifically for adrenocorticosteroid hormone (ACTH). The cortisol test is an indirect but accurate measure of ACTH. The panel is useful to assess hypothalamic/pituitary/adrenal interaction.

80200 80200

80432

Tobramycin

Explanation This drug is also known as Nebcin. This drug has bactericidal properties and is usually injected. Specimen collection is at peak and trough. Peak will occur about one hour after an intramuscular injection and trough will occur about 12 hours after that. Method will often be by radioimmunoassay (RIA), microbiological assay, or high performance liquid chromatography (HPLC).

694

CPT only © 2011 American Medical Association. All Rights Reserved.

© 2011 Optum