Providers should not order one of the organ- or disease-oriented panels simply as a convenience. If medical necessity is not present for even one of the tests on a panel, then the panel should be “broken,” and the medically necessary tests reported individually. CMS maintains the list of appropriate diagnosis codes for each test. If you order a test that is not on the list of approved tests for the diagnosis code(s) you have listed for the patient, you will likely not receive payment for the test. Providers should contact their Medicare carrier for the approved list of ICD-9-CM codes for each test you routinely order. In many cases, carriers have removed the nonspecific or unspecified diagnosis codes from the approved lists. Health professionals should keep in mind that it is fraudulent to list a diagnosis that is not present so that a test will be covered. However, it is not fraudulent to make a specific diagnosis based on your nonlab findings and then change the diagnosis if the lab work does not support your earlier conclusion.
Labs
To order lab tests for arthritis, the physician must order each of the tests individually as follows: uric acid, blood, chemical (CPT 84550); sedimentation rate, erythrocyte, nonautomated (CPT 85651); fluorescent antibody, screen, each antibody (CPT 86255); and rheumatoid factor, qualitative (CPT 86430).
Physician practices should always refer to the AMA CPT manual for a complete list of the appropriate codes. These tests include, but are not limited to, erythrocyte sedimentation rate, synovial fluid analysis, complete blood count (CBC), fecal occult blood test, urinalysis, quantitative rheumatoid factor screen spun microhematocrit, antinuclear antibodies (ANA), complement functional activity, anti-DNA and anti-DNA titer. What many rheumatology practices may not know is that there is a code to describe rheumatoid titer (CPT 86431, quantitative), as well as rheumatoid factor (CPT 86430, screen). Tissue typing can be coded as a single antigen (e.g., HLAB27 [CPT 86812]) or multiple antigens (CPT 86813). A separate code is utilized for HLADR/DQ typing, with codes for single antigen (CPT 86816) and for multiple antigens (CPT 86817).
Separate codes for complement C3 and complement C4 have been deleted from the CPT manual. If reporting C3 and C4 during the same visit, use CPT 86160 and indicate two units under 24G (days or units) on the CMS 1500 form. There is a separate CPT code, 86162, for CH50. If coding for an individual complement (i.e., C2), use CPT 86160 also.
Synovial Fluid Examination
Synovial fluid examinations should be coded as follows:
- Gross examination (CPT 85810)
- Viscosity
- Color
- Clarity
- Cell count miscellaneous body fluids except blood
- Total white cell (CPT 89050)
- Total white cell count plus differential (89051)
- Crystal identification by light microscopy with or without polarizing lens analysis only body fluid; (except urine) (89060)
- Glucose quantitative blood (except reagent strip) (CPT 82947) (list the body fluid being analyzed in the narrative field)
Drug Monitoring
Keep in mind that Medicare carefully monitors follow-up testing. Listing disease-specific diagnosis codes will be insufficient to prove medical necessity for drug monitoring. Health professionals must also list the ICD-9-CM codes that support medical necessity for high-risk medications. These include:
