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

Transcription

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

2 Contents Introduction Coding Systems Claim Forms Contents and Format of This Guide The Reimbursement Process Coverage Issues Payer Types Payment Methodologies Laboratory and Payment Reimbursement Calculating Costs Other Factors Influencing Payment Participation in Medicare Plans Supplemental Medicare Coverage Workers Compensation Documentation An Overview Methods of Documentation General Guidelines for Documentation Principles of Documentation Fraud and Abuse Compliance Action Plan Claims Processing What to Include on Claims Clean Claims The Health Insurance Portability and Accountability Act Processing the Claim Collection Policies Appeals Process Medicare Benefit Notices Automated Response Unit CMS Electronic Claim Completion UB CPT Definitions and Guidelines Structure of CPT CPT Coding Conventions Unlisted Procedures Modifiers Payment for Laboratory Services Venous and Arterial ( ) Nuclear Medicine Gastrointestinal System ( ) Organ or Disease Oriented Panels ( ).. 83 Drug Testing ( ) Therapeutic Drug Assays ( ) Evocative/Suppression Testing ( ) Consultations (Clinical Pathology) ( ). 92 Urinalysis ( ) Chemistry ( ) Hematology and Coagulation ( ) Immunology ( ) Transfusion Medicine ( ) Microbiology ( ) Postmortem Examination ( ) Cytopathology ( ) Cytogenetic Studies ( ) Surgical Pathology ( ) Transcutaneous Procedures (88400) Other Procedures ( ) Reproductive Medicine Procedures ( ) 233 Category II Codes Category III Codes CPT Index ICD-9-CM Definitions and Guidelines The Structure of ICD-9-CM The Structure of the Alphabetic Index The Structure of the Tabular List General Coding Guidelines HCPCS Level II Definitions and Guidelines Introduction Level II National Codes Level III Local Codes Structure and Use of HCPCS Level II Codes The Conventions: Symbols and Modifiers HCPCS Level II Codes HCPCS Level II Index Medicare Official Regulatory Information Revisions to the CMS Manual System National Coverage Determinations Manual Medicare Benefit Policy Manual Pub. 100 References Glossary Correct Coding Initiative Appendix CLIA Waived Tests CD Links from CPT Codes to ICD-9-CM HCPCS Codes

3 CPT Definitions and Guidelines For H. pylori breath test see codes Organ or Disease Oriented Panels ( ) Report organ or disease oriented panel codes only when each panel component in the panel definition is performed. The assignment of organ or disease oriented panel codes is optional for most non Medicare payers. You may assign an organ or disease panel code or opt to report each individual assay code. Medicare guidelines states that if all tests of a CPT defined panel are performed, the provider may bill the panel code or the individual component test codes. The panel codes may be used when the tests are ordered as that panel or if the individual component tests of a panel are ordered separately.for example, if the individually ordered tests are cholesterol (CPT code 82465), triglycerides (CPT code 84478), and HDL cholesterol (CPT code 83718), the service could be billed as a lipid panel (CPT code 80061) Basic metabolic panel A basic metabolic panel includes the following tests: calcium (82310), carbon dioxide (82374), chloride (83435), creatinine (82565), glucose (82947), potassium (84132), sodium (84295), and urea nitrogen (BUN) (84520). Blood specimen is obtained by venipuncture. See the specific codes for additional This panel must include the following: Calcium (82310) Carbon dioxide (82374) Chloride (82435) Creatinine (82565) Glucose (82947) Potassium (84132) Sodium (84295) Urea nitrogen (BUN) (84520). Code cannot be reported in conjunction with General health panel A general health panel includes the following tests: albumin (82040), total bilirubin (82247), calcium (82310), carbon dioxide (bicarbonate) (82374), chloride (82435), creatinine (82565), glucose (82947), alkaline phosphatase (84075), potassium (84132), total protein (84155), sodium (84295), aspartate amino transferase (AST) (SGOT) (84450), urea nitrogen (BUN) (84520), and thyroid stimulating hormone (84443). In addition, this panel includes a hemogram as described by or Blood specimen is obtained by venipuncture. See specific codes for additional Electrolyte panel An electrolyte panel includes the following tests: carbon dioxide (82374), chloride (82435), potassium (84132), and sodium (84295). Blood specimen is obtained by venipuncture. See specific codes for additional This panel is a component of the renal function panel, CPT Comprehensive metabolic panel A comprehensive metabolic panel includes the following tests: albumin (82040), total bilirubin (82247), calcium (82310), carbon dioxide (bicarbonate) (82374), chloride (83435), creatinine (82565), glucose (82947), alkaline phosphatase (84075), potassium (84132), total protein (84155), sodium (84295), alanine amino transferase (ALT) (SGPT) (84460), aspartate amino transferase (AST) (SGOT) (84450), and urea nitrogen (BUN) (84520). Blood specimen is obtained by venipuncture. See the specific codes for additional information about the listed tests. Code can not be used in addition to CPT codes and Obstetric panel An obstetric panel includes the following tests: Hepatitis B surface antigen (HBsAg) (87340), rubella antibody (86762), syphilis test (VDRL, RPR, ART) (86592), RBC antibody screen (86850), ABO blood typing (86900), and Rh (D) blood typing (86901). In addition, this panel includes a hemogram as described by either or Blood specimen is obtained by venipuncture. See specific codes for additional Lipid panel 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 A national coverage determination (NCD) exists for this code. See Medicare National Coverage Determinations Manual, Pub , sec 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. See appendix 1 for CLIA waived kits and test systems. CPT Definitions CPT only 2005 American Medical Association. All Rights Reserved Ingenix, Inc. + Add-On Code K Conscious sedation * Modifier 51 Exempt l New Codes s Changed Codes 83

4 Coding and Payment Guide for Laboratory Services HCPCS Definitions B codes B4034 B9999 Enteral and Parenteral Therapy C codes C1000 C9999 Temporary Codes for use with Outpatient PPS D codes D0120 D9999 Dental Procedures E codes E0100 E9999 Durable Medical Equipment G codes G0001 G9999 Temporary Procedures/ Professional Services H codes H0001 H9999 Alcohol and Drug Abuse Treatment Services J codes J0120 J9999 Drugs Administered Including Oral and Chemotherapy Drugs K codes K0001 K9999 Durable Medical Equipment Prosthetics, Orthotics, Supplies and Dressings (DMEPOS) L codes L0100 L9999 Orthotic and Prosthetic Procedures, Devices M codes M0064 M9999 Medical Services P codes P2028 P9999 Pathology and Laboratory Services Q codes Q0035 Q9999 Miscellaneous Services (Temporary Codes) R codes R0070 R9999 Radiology Services T codes T1000 T9999 Medical Services S codes S0009 S9999 Commercial Payers (Temporary Codes) V codes V2020 V9999 Vision, Hearing and Speech- Language Pathology Services Section Guidelines Examine the instructions found at the beginning of each of the 17 sections. Instructions include the guidelines, notes, unlisted procedures, special reports, and the modifiers that pertain to each section. Use the alphabetic index to initially locate a code by looking for the type of service or procedure performed. The same rule applies: never code directly from the index. Always check the specific code in the appropriate section. The Conventions: Symbols and Modifiers Symbols Symbols used in the HCPCS Level II system may be presented in various ways, depending on the vendor. Ingenix follows the pattern established by the AMA in the CPT code books. For example, bullets and triangles signify new and revised codes, respectively. When a code is new to the HCPCS Level II system, a bullet (l) appears to the left of the code. This symbol is consistent with the CPT symbol for new codes. The bullet represents a code never before seen in the HCPCS coding system. Example l S3854 Gene expression profiling panel for use in the management of breast cancer treatment A triangle (s) is used (as in the CPT system) to indicate that a change in the narrative of a code has been made from the previous year s edition. The change made may be slight or significant, but it usually changes the application of the code. Example s A9529 Iodine Sodium iodide solution, diagnostic, per millicurie HCPCS Level II Codes G Codes Procedures/Professional Services (Temporary) G0000 G9999) G0027 Semen analysis; presence and/or motility of sperm excluding Huhner Semen analysis is the microscopic examination of semen for the presence, quality, and mobility of the sperm contained within the semen. This is usually performed to determine if this is the source of infertility. G0103 Prostate cancer screening; prostate specific antigen test (PSA), total This code reports a total prostate specific antigen (PSA) test for cancer screening. The specimen collection is by venipuncture. Methods may include radioimmunoassay (RIA) and monoclonal two-site immunoradiometric assay. There are several forms of PSA present in serum. PSA may be complexed with the protease inhibitor alpha-1 antichymotrypsin (PSA-ACT) or found in a free form. Higher levels of free PSA are more often associated with benign conditions than with cancer. Total PSA measures both complexed and free levels to provide a total amount present in the serum. A percentage of each form is sometimes calculated to help distinguish benign from malignant conditions. G0107 Colorectal cancer screening; fecal-occult blood test, 1-3 simultaneous determinations A fecal occult blood test with one to three determinations is done for colorectal cancer screening. A fecal sample is dispersed in a diluent with antibodies for hemoglobin antigen to form a complex of antibody and antigen. A complex of antibody and antigen is separated from the specimen and exposed to a second antibody for the hemoglobin antigen, and a portion of the antibody. A sample from the first complex is bound to a solid carrier and a sample from the second antibody exposure is labeled with a detection agent to determine the presence of hemoglobin antigen in the original fecal specimen. This code requires three samples, which must be obtained from separate bowel movements, and each sample must be placed in a sterile leakproof container with a screw-cap lid for transport to the laboratory. 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. See appendix 1 for CLIA-waived kits and test systems. Medicare covers colorectal screening for 300 l New Codes s Changed Codes MED: Medicare Reference 2005 Ingenix, Inc.

5 Correct Coding Initiative v Indicates a mutually exclusive edit 0023T 0026T T 0041T 0058T , 36405, 37202, , , , 64475, 69990, G0345, G0347, G0351-G , 36410, , 37202, , , , 64475, 69990, , 36410, 36430, v, 37202, , 64415, 64417, , 64475, 69990, , , , , , , , , , , , 36410, 36430, v, 37202, , 64415, 64417, , 64475, 69990, , , , , , , , , , , , 36002, , 36410, 36625, 37202, , , , 64475, 69990, 76003, G0345, G0347, G0351- G v, 82310, 82374, 82435, 82565, 82947, 84132, 84295, , 82435, 84132, , 80051, 80069, 80076, 82040, 82247, 82310, 82374, 82435, 82565, 82947, 84075, 84132, 84155, 84295, 84450, 84460, , 82465, 83718, 83721, , 80051, 82040, 82310, 82374, 82435, 82565, 82947, 84100, 84132, 84295, , 86709, 86803, , , 84075, 84155, 84450, , , , v, , , 82533, v, , 82533, , 82088, CCI CPT only 2005 American Medical Association. All Rights Reserved Ingenix, Inc. 335