Coding and Payment Guide for Laboratory Services An essential coding, billing, and payment resource for laboratory and pathology services
Contents Introduction............................... 1 Coding Systems............................... 1 Claim Forms.................................. 2 Contents and Format of This Guide............... 3 The Reimbursement Process.................. 5 Coverage Issues................................ 5 Payer Types................................... 5 Payment Methodologies........................ 6 Laboratory and Payment Reimbursement.......... 8 Calculating Costs............................. 18 Other Factors Influencing Payment.............. 18 Participation in Medicare Plans................. 26 Supplemental Medicare Coverage................ 28 Workers Compensation........................ 32 Documentation An Overview................ 33 Methods of Documentation.................... 33 General Guidelines for Documentation........... 34 Principles of Documentation................... 34 Fraud and Abuse.............................. 36 Compliance.................................. 38 Action Plan.................................. 38 Claims Processing......................... 39 What to Include on Claims..................... 39 Clean Claims................................ 40 The Health Insurance Portability and Accountability Act......................... 40 Processing the Claim.......................... 44 Collection Policies............................ 44 Appeals Process.............................. 45 Medicare Benefit Notices....................... 47 Automated Response Unit...................... 50 CMS-1500................................... 50 Electronic Claim Completion................... 63 UB-92...................................... 69 CPT Definitions and Guidelines............... 73 Structure of CPT.............................. 73 CPT Coding Conventions...................... 73 Unlisted Procedures........................... 73 Modifiers.................................... 74 Payment for Laboratory Services................. 74 Venous and Arterial (36415 36600).............. 81 Nuclear Medicine Gastrointestinal System (78267 78268).................... 82 Organ or Disease Oriented Panels (80048 80076).. 83 Drug Testing (80100 80103).................... 84 Therapeutic Drug Assays (80150 80299).......... 85 Evocative/Suppression Testing (80400 80440)..... 89 Consultations (Clinical Pathology) (80500 80502). 92 Urinalysis (8100 81099)....................... 92 Chemistry (82000 84999)..................... 94 Hematology and Coagulation (85002 85999).... 147 Immunology (86000 86849).................. 159 Transfusion Medicine (86850 86999)........... 183 Microbiology (87001 87999).................. 187 Postmortem Examination (88000 88099)....... 214 Cytopathology (88140 88199)................. 217 Cytogenetic Studies (88230 88299)............ 220 Surgical Pathology (88300 88309)............. 224 Transcutaneous Procedures (88400)............ 230 Other Procedures (89049 89240).............. 230 Reproductive Medicine Procedures (89250 89356) 233 Category II Codes............................ 236 Category III Codes........................... 236 CPT Index............................... 237 ICD-9-CM Definitions and Guidelines......... 259 The Structure of ICD-9-CM.................... 259 The Structure of the Alphabetic Index........... 259 The Structure of the Tabular List................ 259 General Coding Guidelines.................... 261 HCPCS Level II Definitions and Guidelines..... 299 Introduction................................ 299 Level II National Codes....................... 299 Level III Local Codes......................... 299 Structure and Use of HCPCS Level II Codes...... 299 The Conventions: Symbols and Modifiers........ 300 HCPCS Level II Codes........................ 300 HCPCS Level II Index...................... 311 Medicare Official Regulatory Information...... 313 Revisions to the CMS Manual System............ 313 National Coverage Determinations Manual....... 314 Medicare Benefit Policy Manual................ 314 Pub. 100 References.......................... 315 Glossary................................ 321 Correct Coding Initiative................... 335 Appendix CLIA Waived Tests............... 353 CD Links from CPT Codes to ICD-9-CM HCPCS Codes
CPT Definitions and Guidelines For H. pylori breath test see codes 83013 83014. Organ or Disease Oriented Panels (80048 80076) 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). 80048 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 80048 cannot be reported in conjunction with 80053. 80050 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 85004 85009 or 85025 85027. Blood specimen is obtained by venipuncture. See specific codes for additional 80051 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 80069. 80053 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 80053 can not be used in addition to CPT codes 80048 and 80076. 80055 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 85022 or 85025. Blood specimen is obtained by venipuncture. See specific codes for additional 80061 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. 100 03, sec. 100.26. 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. 2005 Ingenix, Inc. + Add-On Code K Conscious sedation * Modifier 51 Exempt l New Codes s Changed Codes 83
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 1-131 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.
Correct Coding Initiative v Indicates a mutually exclusive edit 0023T 0026T 80500-80502 0030T 0041T 0058T 01999 36450 36000, 36405, 37202, 62318-62319, 64415-64417, 64450-64470, 64475, 69990, G0345, G0347, G0351-G0354 36455 36000, 36410, 36420-36425, 37202, 62318-62319, 64415-64417, 64450-64470, 64475, 69990, 36511 36000, 36410, 36430, 36512-36516 v, 37202, 62318-62319, 64415, 64417, 64450-64470, 64475, 69990, 99201-99220, 99231-99236, 99261-99285, 99291-99296, 99298-99299, 99301-99303, 99311-99316, 99321-99323, 99331-99333, 99341-99350, 36513 36000, 36410, 36430, 36514-36516 v, 37202, 62318-62319, 64415, 64417, 64450-64470, 64475, 69990, 99201-99220, 99231-99236, 99261-99285, 99291-99296, 99298-99299, 99301-99303, 99311-99316, 99321-99323, 99331-99333, 99341-99350, 36600 36000, 36002, 36120-36140, 36410, 36625, 37202, 62318-62319, 64415-64417, 64450-64470, 64475, 69990, 76003, G0345, G0347, G0351- G0354 80048 80051 v, 82310, 82374, 82435, 82565, 82947, 84132, 84295, 84520 80050 80051 82374, 82435, 84132, 84295 80053 80048, 80051, 80069, 80076, 82040, 82247, 82310, 82374, 82435, 82565, 82947, 84075, 84132, 84155, 84295, 84450, 84460, 84520 80055 80061 80500-80502, 82465, 83718, 83721, 84478 80069 80048, 80051, 82040, 82310, 82374, 82435, 82565, 82947, 84100, 84132, 84295, 84520 80074 86705, 86709, 86803, 87340 80076 82040, 82247-82248, 84075, 84155, 84450, 84460 80100 80101, 80500-80502, 82486-82489 80101 80500-80502, 83516-83518 80102 80500-80502 80103 80150 80152 80154 80156 80157 80158 80160 80162 80164 80166 80168 80170 80172 80173 80174 80176 80178 80182 80184 80185 80186 80188 80190 80192 80190 80194 80195 80196 80197 80198 80200 80201 80202 80400 80402-80406 v, 80500-80502, 82533 80402 80500-80502, 82533, 83498 80406 80402 v, 80500-80502, 82533, 84143 80408 80500-80502, 82088, 84244 CCI CPT only 2005 American Medical Association. All Rights Reserved. 2005 Ingenix, Inc. 335