Editor’s note: This is the conclusion of a two-part article. In the first part, which appeared in the April issue, we discussed the quality standards that are required to perform labs in the physician office. As we venture into another area, we will attempt to cover the basic steps that will assist in office compliance, as well as efficient coding and reimbursement.
Laboratory coding has nuances, but is under the same AMA guidelines of proper coding as all other clinical areas. The rheumatologist and other nonphysician providers in rheumatology practices must be certain that the correct code is applied to ensure accurate diagnosing of patients and proper reimbursement. Laboratory tests are an important tool in treating patients with autoimmune disorders.
In the world of labs, there is a great quantity of labs available for providers to utilize in treating and managing patients with autoimmune disorders. The most common lab tests used day to day in rheumatology practices are C-reactive protein, sedimentation rate, rheumatoid factor, complete blood count, urinalysis, comprehensive metabolic panel, antinuclear and uric acid. Any of these can be ordered individually or in combination, as determined by the health professional. A complete guide to ensure proper coding and billing follows.
Blood Counts
Not only are these codes for manual and automated performances of complete blood counts, there are also codes for each component. Nurse practitioners and physician assistants should refer to the index in the AMA CPT manual for the appropriate list of codes. For most single or small group offices, the codes for hematocrit or blood count other than spun (CPT 85014), colormetric hemoglobin (CPT 85018), manual cell count (CPT 85032) and automated hemogram (CPT 85025–85027) may be the ones most frequently applied. It’s recommended that your billing form list those tests that regularly apply to your practice.
Urinalyses
Urinalyses (CPT 81000–81020) can be listed as a complete routine (with pH, specific gravity, protein, reducing substance and microscopy) or by constituent subsets (complete microscopy) or qualitative chemical analysis with any number of constituents.
Cultures
Body fluids cultures may be described using CPT codes 87040–87999, depending on the site or origin and the type of culture obtained. Urine cultures are usually performed in a quantitative manner with colony counts. Use CPT 87088 if the test was performed with a commercial kit for organism identification in addition to the culture codes themselves, and use CPT 87086 if the rest was performed by another method.
Organ or Disease Oriented Panel
Lab panels have undergone significant changes in the past few years, and they remain a source of confusion. There is no longer a list of automated multichannel tests. Tests should be reported individually unless they compose one of the nine organ- or disease-oriented panels.
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:
V58.65 Long-term (current) use of steroids
V58.69 Long-term (current) use of other (high-risk) medications
V67.51 Following completed treatment with high-risk medications, not elsewhere classified
Health professionals in rheumatology practices must be certain that the correct code is applied to lab tests to ensure proper reimbursement. Offices that process laboratory tests should follow the guidelines listed below:
- If you do testing in your own laboratory, bill for the test using the appropriate laboratory code number, in addition to the office visit.
- If specimen is collected and sent to an outside laboratory, bill for the office visit and a handling fee (CPT codes 99000–99002) or add the modifier “90” (or the five-digit modifier 09990) with the code for the test performed. This alerts third-party payers that an outside laboratory performed the tests and supports the billing by both the rheumatology practice and the laboratory.
Note: Medicare does pay for 36415 (venipuncture) to draw the blood specimen, but does not pay for CPT codes 99000–99002; however private payer payments vary. - If the laboratory bills you for the test, bill the patient using the appropriate code from the laboratory section of the CPT manual. This applies only to non-Medicare patients who have laboratory tests performed by an outside laboratory; this must be billed directly by the outside lab. It should be noted that, at least in a few states, Medicaid and other third-party payers stipulate the same requirements.
- If a specific code for a test cannot be located in the AMA CPT manual, you should try to locate the code based on the method of performing the test. Refer to the subsection information under the guidelines for the pathology and laboratory section.
- The allowable laboratory tests reimbursed for particular diagnoses are carefully monitored. The physician or healthcare provider should consult their Medicare carrier’s bulletin to identify the laboratory tests that will be reimbursed only if it corresponds with the medically necessary diagnosis list.
The complexity of clinical laboratory billing, ever-increasing regulatory demands, inadequate legacy applications and difficulties accessing information can impede growth and hinder the success of your practice. Rheumatology practices face an overwhelming number of challenges when it comes to ordering and billing labs, and it is important to stay abreast of each payer’s guidelines and regulations for billing lab charges.
For more information or questions on coding and billing, contact the ACR practice management team at [email protected].
