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

2011

Contents Introduction ......................................................................1 Coding Systems .................................................................... 1 Claim Forms ......................................................................... 2 Contents and Format of This Guide ...................................... 2 How to Use This Guide ......................................................... 3

The Health Insurance Portability and Accountability Act ...... 46 Processing the Claim ...........................................................49 Medicare Benefit Notices .....................................................51 The CMS-1500 Claim Form ................................................. 56 The UB-04 Claim Form ........................................................69

The Reimbursement Process .............................................5 Coverage Issues .................................................................... 5 Payer Types .......................................................................... 5 Payment Methodologies ....................................................... 9 Laboratory and Pathology Reimbursement ......................... 11 Calculating Costs ................................................................ 20 Other Factors Influencing Payment ..................................... 21 Workers’ Compensation ...................................................... 35 Collection Policies ............................................................... 35

Procedure Codes..............................................................77 CPT Coding Conventions .................................................... 77 Unlisted Procedures ............................................................. 78 Modifiers ............................................................................. 78 Payment for Laboratory Services .......................................... 78 Procedure Codes .................................................................. 95

Documentation—An Overview .......................................37 Methods of Documentation ................................................ 37 General Guidelines for Documentation ............................... 38 Fraud and Abuse ................................................................. 39 Compliance ........................................................................ 42 Action Plan ......................................................................... 42 Claims Processing ...........................................................45 What to Include on Claims ................................................. 45 Clean Claims ...................................................................... 46

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CPT Index ......................................................................773 ICD-9-CM Diagnosis Codes ...........................................785 The Structure of ICD-9-CM ...............................................785 The Structure of the Tabular List ........................................785 General Coding Guidelines ................................................787 Medicare Official Regulatory Information ...................789 Glossary .........................................................................795 Appendix—CLIA Waived Tests .....................................807

CPT codes only © 2010 American Medical Association. All Rights Reserved.

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Introduction

Coding and Payment Guide for Laboratory Services

HCPCS Level I or CPT Codes The Centers for Medicare and Medicaid Services (CMS), in conjunction with the American Medical Association (AMA), the American Dental Association (ADA), and several other professional groups developed, adopted, and implemented a coding system describing services rendered to patients. Known as HCPCS Level I, the CPT coding system is the most commonly used system to report medical services and procedures. Copyright of CPT codes and descriptions is held by the AMA. This system reports outpatient and provider services. CPT codes predominantly describe medical services and procedures, and are adapted to provide a common billing language that providers and payers can use for payment purposes. The codes are widely used and required for billing by both private and public insurance carriers, managed care companies, and workers’ compensation programs. The AMA’s CPT Editorial Panel reviews the coding system and adds, revises, and deletes codes and descriptions. The panel accepts information and feedback from providers about new codes and revisions to existing codes that could better reflect the provided services or procedures. The majority of codes are found in category I of the CPT coding system. These five-digit codes describe procedures and services that are customarily performed in clinical practices.

of one alphabetic character (A through V) followed by four numbers. Non-Medicare acceptance of HCPCS Level II codes is idiosyncratic. Providers should check with the payer before billing these codes.

Claim Forms Institutional (facility) providers use the UB-04 claim form, also known as the CMS-1450, or the electronic 837I format to file a Medicare Part A claim to Medicare fiscal intermediaries (FI). Noninstitutional providers and suppliers (private practice or other health care providers offices) use the CMS-1500 form or the 837P electronic format to submit claims to Medicare Carriers for Medicare Part B covered services. Medicare Part A coverage includes inpatient hospital, skilled nursing facilities (SNF), hospice, and home 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.

CPT category II codes are supplemental tracking codes that are primarily used when participating in the Physician Quality Reporting Initiative (PQRI) established by Medicare and are intended to aid in the collection of data about quality of care. At the present time, participation in this program is optional and providers should not report these codes if they elect not to participate. Category II codes are alphanumeric, consisting of four digits followed by an “F” and should never be used in lieu of a category I CPT code. A complete list of the category II codes can be found at the AMA website at http://www.ama-assn.org/go/cpt.

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.

Category III of the CPT coding system contains temporary tracking codes for new and emerging technologies that are meant to aid in the collection of data on these new services and procedures. CPT category III codes consist of four numeric digits followed by a “T.” Like category II codes, category III codes are released twice a year (January 1 and July I) and can be found on the AMA CPT website at http://www.ama-assn.org/go/cpt. RVUs are not assigned for category III codes and payment is made at the discretion of the payer. A services described by a CPT may eventually become a category I code, as the efficacy and safety of the service is documented.

Contents and Format of This Guide

HCPCS Level II Codes HCPCS Level II codes are commonly referred to as national codes or by the acronym HCPCS (Healthcare Common Procedure Coding System, pronounced hik-piks). HCPCS codes are used to bill Medicare and Medicaid patients and are also used by some third-party payers. HCPCS Level II codes, periodically updated and published annually by CMS, are intended to supplement the CPT coding system by including codes for nonphysician services, durable medical equipment (DME), and office supplies. These Level II codes consist

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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 book.

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, Centers for Medicare and Medicaid Services (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.

CPT codes only © 2010 American Medical Association. All Rights Reserved.

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Procedure Codes

Coding and Payment Guide for Laboratory Services

84155-84160 84155

Protein, total, except by refractometry; serum, plasma or whole blood

84156

urine

84157

other source (eg, synovial fluid, cerebrospinal fluid)

84160

Protein, total, by refractometry, any source

262 263.0 263.1 263.8 579.8 580.0 580.4

Explanation A total protein test may be performed to assess nutritional status. Serum, plasma, or whole blood is tested for protein in 84155. Synovial, cerebrospinal, or other fluid is obtained in 84157. A urine specimen is required for 84156. For amniotic fluid specimen (84157), a separately reportable amniocentesis is performed. Aspiration of other body fluids (CSF, bronchial fluid, exudates) may also require separately reportable procedures. The method is biuret for blood (serum) and amniotic fluid. The method is turbidimetry or nephelometry for urine and CSF. For other body fluids, the method is turbidimetry or biuret. Code 84160 reports protein tested for by refractometry with any source of specimen. Collection/aspiration of other body fluids (CSF, amniotic fluid, exudates) may require separately reportable procedures. The method determines the velocity of light through a refractive material (plasma).

Coding Tips

580.81

580.89 580.9 581.1 581.9 582.0 582.1

Code 84155 represents a test that 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. See appendix 1 for CLIA-waived kits and test systems. For amniotic fluid specimen, a separately reportable amniocentesis is performed. Aspiration of other body fluids (cerebrospinal fluid [CSF], bronchial fluid, exudates) may also require separately reportable procedures. Venipuncture is separately reportable for collection of venous blood. By venipuncture, see code 36415. For venipuncture on a patient younger than 3 years of age, see codes 36400-36406. When venipuncture on a patient 3 years of age or older requires physician skill, see code 36410. If a specimen is transported to an outside laboratory, report code 99000 for handling or conveyance.

Terms To Know aspiration. Drawing fluid out by suction. CSF. Cerebrospinal fluid. 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.

582.4 582.81

Other severe protein-calorie malnutrition Malnutrition of moderate degree Malnutrition of mild degree Other protein-calorie malnutrition Other specified intestinal malabsorption Acute glomerulonephritis with lesion of proliferative glomerulonephritis Acute glomerulonephritis with lesion of rapidly progressive glomerulonephritis Acute glomerulonephritis with other specified pathological lesion in kidney in disease classified elsewhere — (Code first underlying disease: 002.0, 070.0-070.9, 072.79, 421.0) Other acute glomerulonephritis with other specified pathological lesion in kidney Acute glomerulonephritis with unspecified pathological lesion in kidney Nephrotic syndrome with lesion of membranous glomerulonephritis Nephrotic syndrome with unspecified pathological lesion in kidney Chronic glomerulonephritis with lesion of proliferative glomerulonephritis Chronic glomerulonephritis with lesion of membranous glomerulonephritis Chronic glomerulonephritis with lesion of rapidly progressive glomerulonephritis Chronic glomerulonephritis with other specified pathological lesion in kidney in diseases classified elsewhere — (Code first underlying disease: 277.30-277.39, 710.0)

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 100-2,11,30.2.2; 100-2,15,80; 100-3,190.10; 100-4,3,10.4; 100-4,12,30; 100-4,16,70.8

CCI Version 16.3 Also not with 84155: 84160v Also not with 84160: 84156-84157v Note: These CCI edits are used for Medicare. Other payers may reimburse on codes listed above.

ICD-9-CM Diagnostic Codes 203.00 203.01 203.02 261

Multiple myeloma, without mention of having achieved remission Multiple myeloma in remission Multiple myeloma, in relapse Nutritional marasmus Work Value

84155........................ 0.00 84156........................ 0.00 84157........................ 0.00 84160........................ 0.00

272

Non-Fac PE

Fac PE

Malpractice

Non-Fac Total

Fac Total

0.00 0.00 0.00 0.00

0.00 0.00 0.00 0.00

0.00 0.00 0.00 0.00

0.00 0.00 0.00 0.00

0.00 0.00 0.00 0.00

CPT only © 2010 American Medical Association. All Rights Reserved.

© 2010 Ingenix

© 2010 Ingenix

Urine pregnancy tests by visual color comparison

Fecal occult blood

Blood glucose by glucose monitoring devices cleared by the FDA for home use

Hemoglobin by copper sulfate – nonautomated

Ovulation tests by visual color comparison for human luteinizing hormone

Blood count; spun microhematocrit

Erythrocyte sedimentation rate – nonautomated

82270 82272 (Contact your Medicare carrier for claims instructions.)

82962

83026

84830

85013

85651

Dipstick or tablet reagent urinalysis – non-automated for bilirubin, glucose, hemoglobin, ketone, leukocytes, nitrite, pH, protein, specific gravity, and urobilinogen

81002

81025

TEST NAME

CPT CODE(S)

CPT codes only © 2010 American Medical Association. All Rights Reserved.

Various

Various

Various

Various

Various

Various

Various

Various

MANUFACTURER

Nonspecific screening test for inflammatory activity, increased for majority of infections, and most cases of carcinoma and leukemia

Screen for anemia

Detection of ovulation (optimal for conception)

Monitors hemoglobin level in blood

Monitoring of blood glucose levels

Detection of blood in feces from whatever cause, benign or malignant (colorectal cancer screening)

Diagnosis of pregnancy

Screening of urine to monitor/diagnose various diseases/conditions, such as diabetes, the state of the kidney or urinary tract, and urinary tract infections

USE

TESTS GRANTED WAIVED STATUS UNDER CLIA

Appendix—CLIA Waived Tests

807