Steps to Help Rheumatologists Achieve Office Compliance in Laboratory Coding

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:

1. If you do testing in your own laboratory, bill for the test using the appropriate laboratory code number, in addition to the office visit.
2. 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.
3. 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.
4. 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.
5. 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].