Coding Laboratory Services

Audio Seminar/Webinar
June 4, 2009

Practical Tools for Seminar Learning

© Copyright 2009 American Health Information Management Association. All rights reserved.
Disclaimer

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differences of opinion or disputes with Medicare or other third party payers
as to the amount that will be paid to providers of service.

CPT® five digit codes, nomenclature, and other data are copyright 2009
American Medical Association. All Rights Reserved. No fee schedules, basic
units, relative values or related listings are included in CPT®. The AMA
assumes no liability for the data contained herein.

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presentation.

AHIMA 2009 Audio Seminar Series • http://campus.ahima.org/audio i

American Health Information Management Association • 233 N. Michigan Ave., 21st Floor, Chicago, Illinois
Faculty

Betty Hatten, MHS, MT

Betty Hatten is a manager in Huron Consulting Group’s Clinical Research Solutions and
Healthcare Compliance practice. Ms Hatten is a 40 year veteran of the healthcare
industry, including the past 11 as a healthcare consultant focusing on coding and
compliance, charge capture, performance improvement, and chargemaster
development and maintenance. A medical technologist for 28 years, her experience
includes clinical laboratories, genetics and transplant labs, in vitro fertilization labs,
educator, and laboratory administrative director.

Diana Medal, MA, RHIA, CCS, CPC, CCS-P

Diana Medal is a compliance practice leader in the care delivery section of Kaiser
Permanente’s national Compliance, Ethics, and Integrity team, where she is
responsible for coordinating coding compliance training and supporting coding
compliance audits. Ms Medal was previously assistant professor of health information
administration at Loma Linda University. She also participated in global distance
instruction for Loma Linda, as medical terminology instructor for physical and
occupational therapy students in Yokkaichi, Japan.

AHIMA 2009 Audio Seminar Series ii

Table of Contents

Disclaimer ..................................................................................................................... i
Faculty ......................................................................................................................... ii
The Objectives ............................................................................................................... 1
The Agenda ................................................................................................................... 1
Comparison of Organ & Disease Panels ............................................................................ 2
Lab Coding Tips ............................................................................................................. 3
Online, Free, Lab Coding Reference ................................................................................. 4
Using the Reference Lab Website .................................................................................... 4
Coding Tip: Always Validate Testing Methods: Labs Vary ................................................... 5
2009 CPT Codes.......................................................................................................... 5-7
HCPCS Code Selection .................................................................................................... 7
Polling Question #1 “Source of Diagnostic Information”..................................................... 8
Official Coding Guidelines................................................................................................ 8
Official Coding Guidelines Diagnostic Services Only .......................................................9-10
Coding for Physician Billing Pathologist............................................................................10
Proposed New Codes for FY 2010 ...................................................................................11
Proposed Invalid Codes for FY 2010 ................................................................................11
Pathologist’s Interpretation of a Pap Smear .....................................................................12
Papanicolaou Test Reconfirmation V72.32 .......................................................................12
Abnormal Cytologic Smear of Anus 796.7 ........................................................................13
Other Codes Associated with Anal Pap Smear ..................................................................13
Diagnosis from Ordering Physician vs. Pathologist for Pathologist Claim .............................14
Diagnosis for Urine Culture ............................................................................................14
Diagnosis for Complete Blood Count (CBC) ......................................................................15
Diagnosis for Monitoring Effects of Long-term Use of Drugs ..............................................15
Clinical Laboratory Fee Schedule ............................................................................... 16-17
Physician Fee Schedule ............................................................................................. 17-18
Reimbursement for OPPS Hospital Lab Tests that are Assigned APCs .................................18
Reimbursement for OPPS Hospital Labs...........................................................................19
Addendum B: OPPS Reimbursement ...............................................................................19
Status Indicator Definitions ............................................................................................20
Billing for End Stage Renal Disease (ESRD) Related Laboratory Tests ........................... 20-21
Composite Rate Tests ....................................................................................................22
Polling Question #2 “The Semicolon and Modifiers”..........................................................22
National Correct Coding Initiative ...................................................................................23
Do these 2 Indented Codes Need a Modifier? ............................................................. 23-24
Modifier -59 Distinct Procedural Service...................................................................... 25-26
Polling Question #3 “Use of Modifier -59”........................................................................26
Modifier -91 Repeat Clinical Diagnostic Test .....................................................................27
-59 or -91 Case Study....................................................................................................28
Modifier -90 Reference (Outside) Laboratory ...................................................................29

(CONTINUED)
AHIMA 2009 Audio Seminar Series
Table of Contents
ESRD Modifiers: CD, CE, CF ...................................................................................... 29-30
OIG Work Plan (FY 2009)...............................................................................................30
Why Doctors Order Lab Tests? .......................................................................................31
Information Available for Each “Reason” .........................................................................31
The Need for ABNs: Variable ..........................................................................................32
Screening Tests: Legislative Provisions ............................................................................32
Beneficiary Notices Initiative (BNI) .................................................................................33
The CMSR 131 ......................................................................................................... 33-34
ABN Instructions and Options .........................................................................................34
Guidelines for Coding Blood Transfusions ........................................................................35
Complete Billing of the Blood Transfusion ........................................................................35
Transfusion Medicine Case: The Facts .............................................................................36
Transfusion Medicine Case: The Answer ..........................................................................36
NCCI Edits for Crossmatching .........................................................................................37
Transfusion Medicine Case: The Answer ..........................................................................37
Most Common “Missed” CPT Codes in Lab: Microbiology ...................................................38
Aerobic and Anaerobic Cultures with Blood Cultures .................................................... 38-39
Most Common “Missed” CPT Codes in Lab: Microbiology .............................................. 39-40
For More Information on Laboratory Coding from CPT Assistant ................................... 40-41
Resource/Reference List ........................................................................................... 41-42
Supplemental Material ...................................................................................................43
Other References : Lab Websites ....................................................................................43

Audience Questions .......................................................................................................44

Audio Seminar Discussion ..............................................................................................44
Become an AHIMA Member Today! .................................................................................45
Audio Seminar Information Online ..................................................................................45
Upcoming Audio Seminars ............................................................................................46
Thank You/Evaluation Form and CE Certificate (Web Address) ..........................................46

Appendix ..................................................................................................................47
Resource/Reference List .......................................................................................48
CE Certificate Instructions

AHIMA 2009 Audio Seminar Series

Coding Laboratory Services Notes/Comments/Questions

The Objectives
At the conclusion of today’s program, the
participants will be able to:
1. Select the most accurate lab CPT/HCPCS code;
2. Locate internet resources for coding esoteric lab
procedures and profiles;
3. Identify the appropriate payment programs for OP
lab services including ESRD composite rate, Clinical
Lab Fee schedule and OPPS APCs;
4. Discuss CPT coding guidelines for laboratory
services;
5. Summarize the ICD-9 CM Diagnostic Coding and
Reporting Guidelines for Outpatient Services; and
6. Demonstrate the correct use of modifiers 59 and 91.
1

The Agenda

1. CPT & HCPCS Coding Overview with

Coding TIPS and CAUTIONS
2. ICD-9 Diagnosis & Procedure Coding
3. The Fee Schedules and Addendum B
4. Lab Modifier Maze and the NCCI
5. OIG & the Clinical Lab: Compliance
Guidelines and the 2009 Work Plan
6. Deep Dive into Real Life Lab Coding
Cases
2

AHIMA 2009 Audio Seminar Series 1

Coding Laboratory Services Notes/Comments/Questions

Comparison of
Organ & Disease Panels

Comparison of
Organ & Disease Panels

AHIMA 2009 Audio Seminar Series 2

Coding Laboratory Services Notes/Comments/Questions

Lab Coding Tips

Š Select Accurate 80000 Codes

• Adjectives and other important words
• Specimen , Method, Total or Free, With or
W/out
• Manual or automated, Qual or Quant, initial,
• Each, first, “2-8” or “9-15”
• Antibody codes start with 86xxx; Antigens
start with 87xxx

Lab Coding Tips

• When you need more than one code

• Charge explosions
• Panels , Profiles and Reflex Tests:
Maintaining Compliance
• When there isn’t a code
• Avoid the unlisted procedure code: Use
Method Codes
• How to find esoteric testing codes

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Coding Laboratory Services Notes/Comments/Questions

Online, Free, Lab Coding Reference

Type your
Query or select
from the
alphabet

Using the Reference Lab Website

Queried
“Drug Screen”

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Coding Laboratory Services Notes/Comments/Questions

CODING TIP: Always Validate

Testing Methods: Labs Vary

2009 CPT Codes

Š 83876 Myeloperoxidase (MPO)

• A biomarker used in conjunction with
troponin, CK or CKMB and BNP. ID’s
patients w/chest pain who are at risk for
MI but have a negative troponin or ECG.
Š 83951 Oncoprotein (DCP)
• Oncoprotein biomarker intended for F/U
of patients w/chronic liver disease at risk
for Hepatocellular carcinoma. (Associated
w/a 4.8 increase of HCC w/in next 21
months)
10

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Coding Laboratory Services Notes/Comments/Questions

2009 CPT Codes

Š 85397 Coagulation & Fibrinolysis,

functional activity, NOS, each analyte
• Used in Dx of thrombotic thrombocytopenic
purpura & hemolytic uremic syndrome
(examples of assays i.e., Disintegrin and
metalloproteinase)
Š 87905 Infectious agent enzymatic activity
other than virus (e.g., sialidase
activity in vaginal fluid)
• The test is for bacterial vaginosis with results in
approx 10 minutes. Has a reported sensitivity of
90% 11

2009 CPT Changes

The old subheading following 83999

“Transcutaneous Procedures” was deleted
in 2009 and replaced with the new
subheading “In Vivo (e.g. transcutaneous)
Laboratory Procedures. The new codes
are:
Š 88720 Bilirubin, total transcutaneous
Š 88740 Hemoglobin, quantitative,
transcutaneous, per day;
carboxyhemoglobin
Š 88741 Methemoglobin
12

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Coding Laboratory Services Notes/Comments/Questions

2009 CPT Changes

Š Molecular diagnostics codes 83890-83909

were revised in 2009. These codes
represent molecular diagnostic techniques
for analysis of nucleic acids.
Š Code separately each procedure used in the
analysis.
Š Additional descriptions were added, for
example, “each nucleic acid type (i.e., DNA
or RNA),” “each enzyme treatment,” and
“each nucleic acid preparation.”
13

HCPCS Code Selection

Š Select Accurate HCPCS Codes

• The Blood Products
• P9010 - P9060; J2788 - J2792
• Adding on a 80000 Code to a blood product
• CAUTION: Do not unbundle or double bill

14

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Coding Laboratory Services Notes/Comments/Questions

Polling Question #1
“Source of Diagnostic Information”

A diagnosis was not on the lab order.

Can the lab staff accept the patient’s
reason for why the test has been
ordered?
[*1] Yes
[*2] No

15

Official Coding Guidelines

Š Diagnostic Coding and Reporting

Guidelines for Outpatient Services
• Coding guidelines for inconclusive
diagnoses (probable, suspected, rule out,
etc.) were developed for inpatient
reporting and do not apply to
outpatients.

16

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Coding Laboratory Services Notes/Comments/Questions

Official Coding Guidelines

Diagnostic Services Only

Š Patients receiving diagnostic services

only
• For patients receiving diagnostic services
only during an encounter/visit, sequence
first the diagnosis, condition, problem, or
other reason for encounter/ visit shown
in the medical record to be chiefly
responsible for the outpatient services
provided. Codes for other diagnoses may
be sequenced as additional diagnoses.
17

Official Coding Guidelines

Diagnostic Services Only

• For encounters for routine laboratory

testing in the absence of signs,
symptoms, or associated diagnosis,
assign V72.6.
• If routine testing is performed during the
same encounter as a test to evaluate a
sign, symptom, or diagnosis, it is
appropriate to assign both the V code and
the code describing the reason for the
non-routine test.
18

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Coding Laboratory Services Notes/Comments/Questions

Official Coding Guidelines

Diagnostic Services Only
• For outpatient encounters for diagnostic
tests that have been interpreted by a
physician, and the final report is available
at the time of coding, code any confirmed
or definitive diagnosis(es) documented in
the interpretation. Do not code related
signs and symptoms as additional
diagnoses. Note: This differs from the
coding practice in the hospital inpatient
setting regarding abnormal findings on
tests.

19

Coding for
Physician Billing Pathologist
Š Coding Clinic First Quarter 1990 Page: 15-16
Š When patients receive only ancillary diagnostic
services during an encounter, the appropriate V
code for the examination is sequenced first.
The diagnosis/problem for which the services
are being performed is sequenced second.
Š V72.6 Laboratory examination is used often by
pathologists to describe the reason for the
encounter (e.g. study biopsy specimen). When
the bill is submitted, if there is an established
diagnosis (e.g. malignant neoplasm) then an
additional code can be submitted for the
diagnosis. 20

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Coding Laboratory Services Notes/Comments/Questions

Proposed New Codes for FY 2010

V72.60 Laboratory examination, unspecified

V72.61 Antibody response examination

Laboratory examination ordered as

V72.62 part of a general medical
examination
Pre-procedural laboratory
V72.63
examination

V72.69 Other laboratory examination

21

Proposed Invalid Codes for FY 2010

V72.6 Laboratory examination

22

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Coding Laboratory Services Notes/Comments/Questions

Pathologist’s Interpretation
of a Pap Smear
Scenario: Physician performed a routine
gynecological examination with a pap smear.
The specimen was sent to an external lab.
Conclusion: The pathologist’s interpretation of
the pap smear revealed abnormal cells and
bacterial vaginosis.
Code Assignment: V72.6 as the first listed
diagnosis followed by 616.10.
Rationale: Pathology claims should start with
V72.6. The secondary diagnosis code
represents any definitive diagnostic
information. 23

Papanicolaou Test Reconfirmation

V72.32
Š V72.32 Encounter for Papanicolaou Cervical
Smear to Confirm Findings of Recent Normal
Smear Following Initial Abnormal Smear
Š This code is assigned by the gynecologist and
not the pathologist.
Š It is routine for patients to return for several
Pap tests following an initial abnormal Pap
smear. 1st Pap as part of routine GYN Exam
V72.31. If abnormal, 2nd pap 795.0x. When
result of 2nd Pap is normal, Third pap test is
V72.32, and 4th pap test is V72.32.
24

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Coding Laboratory Services Notes/Comments/Questions

Abnormal Cytologic Smear of Anus

796.7
Š 796.7x may be assigned as a secondary diagnosis
code by the pathologist for abnormal cytologic
smear of anus and anal HPV. V72.6 is principal
diagnosis for pathologist.
Š Human papillomavirus (HPV) can occur in the anus
and is associated with a higher incidence of anal
cancer in HIV patients compared to the general
population.
Š Pap smears are also performed for cytologic
evaluation of the anus, and similar to cervical
cytology, anal cytology uses the Bethesda 2001
system to categorize the abnormalities by
severity. 25

Other Codes Associated with

Anal Pap Smear

Š V76.49 Screening for malignant

neoplasm of other sites
Š 796.77 Satisfactory anal smear but
lacking transformation zone
Š 796.78 Unsatisfactory anal cytology
smear

26

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Coding Laboratory Services Notes/Comments/Questions

Diagnosis from Ordering Physician

vs. Pathologist for Pathologist Claim
Scenario: A physician surgically removed a
skin lesion. The specimen was sent to the
pathologist to determine the nature of the
lesion.
Conclusion: The pathologist confirmed the
lesion to be malignant.
Code Assignment: The pathologist would
report the appropriate malignancy code
dependent on the anatomical site and the
morphology of the neoplasm on his claim.
Rationale: The pathologist is a physician.
27

Diagnosis for Urine Culture

(Note: See Supplemental Materials for Urine Culture Flow Chart)

Scenario: A physician ordered a urinary

culture for a patient experiencing sharp pelvic
pains, a burning sensation in the urethra, and
urine tinged with blood. The physician sent
the urine sample to the lab.
Conclusion: The culture was positive for a
urinary tract infection (UTI).
Code Assignment: The lab would report the
code(s) to describe the symptoms.
Rationale: The urine culture did not have
physician interpretation.
28

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Coding Laboratory Services Notes/Comments/Questions

Diagnosis for
Complete Blood Count (CBC)
Scenario: A physician orders a CBC for a
patient c/o frequent headaches and
lethargy. The blood sample was sent to an
external lab.
Conclusion: The findings were low
hemoglobin and hematocrit.
Code Assignment: the lab would report the
code(s) to describe the symptoms.
Rationale: The blood sample did not have
physician interpretation.
29

Diagnosis for Monitoring Effects of

Long-term Use of Drugs
Š Assign a code from category V58.6x for
patients requiring laboratory monitoring to
asses the effects of Long-term (current) drug
use
• Monitoring for Long-term (current) use of other
medications (i.e., chemotherapy, digitalis)
V58.69 as the principal diagnosis
• Monitoring for Long-term (current) use of
warfarin/Coumadin V58.61
• Monitoring for Long-term (current) use of
aspirin V58.66
• Monitoring for Long-term (current) use of
steroids V58.65 30

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Coding Laboratory Services Notes/Comments/Questions

Clinical Laboratory Fee Schedule

Log on to the CMS website  Scroll down, on the right  In the left hand column, 

at:  hand side click “Medicare‐ click “Fee Schedule”
http://www.cms.hhs.gov/ Fee‐for‐Service Payment”

• Then click “Medicare” • Then click “Clinical  • Clinical Laboratory Fee 

Laboratory Fee  Schedule – Home
Schedule”

31

Clinical Laboratory Fee Schedule

32

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Coding Laboratory Services Notes/Comments/Questions

Clinical Laboratory Fee Schedule

33

Physician Fee Schedule

Log on to the CMS website  Scroll down, on the right  In the left hand column, 

at:  hand side click “Medicare‐ click “Fee Schedule”
http://www.cms.hhs.gov/ Fee‐for‐Service Payment”

• Then click “Medicare” • Then click Physician Fee  • Physician Fee Schedule –

Schedule” Home

Physician Fee Schedule

Physician Fee Schedule

Overview

34

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Coding Laboratory Services Notes/Comments/Questions

Physician Fee Schedule

35

Reimbursement for OPPS Hospital

Lab Tests that are Assigned APCs
Log on to the CMS website  Scroll down, on the right  In the left hand column, 
at:  hand side click “Medicare‐ click “Addendum A and 
http://www.cms.hhs.gov/ Fee‐for‐Service Payment” Addendum B  Updates”

• Then click “Medicare” • Then cllick “Hospital  • Addendum B  April 2009

Outpatient PPS”

Hospital Outpatient PPS

Addendum A and Addendum B Updates

36

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Coding Laboratory Services Notes/Comments/Questions

Reimbursement for
OPPS Hospital Labs

37

Addendum B: OPPS Reimbursement

Status Indicator
identifies
reimbursement
method

38

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Coding Laboratory Services Notes/Comments/Questions

Status Indicator Definitions

39
Click Tab and Scroll

Billing for End Stage Renal Disease

(ESRD) Related Laboratory Tests

40.6 - Medicare Publication 100- 4

Chapter 16
(Rev. 1, 10-01-03) PM AB-98-7, PRM 1
2711, B3-4270.2
Š Hemodialysis, Intermittent Peritoneal
Dialysis (IPD), and Continuous Cycling
Peritoneal Dialysis (CCPD) Tests

40

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Coding Laboratory Services Notes/Comments/Questions

Billing for End Stage Renal Disease

(ESRD) Related Laboratory Tests

Š With some exceptions, laboratory tests for

hemodialysis, intermittent peritoneal
dialysis (IPD), and continuous cycling
peritoneal dialysis (CCPD) are included in
the ESRD composite rate. For a particular
date of service to a beneficiary, if 50
percent or more of the covered laboratory
tests are noncomposite rate tests Medicare
allows separate payment beyond that
included in the composite rate.
41

Billing for End Stage Renal Disease

(ESRD) Related Laboratory Tests
Š For a description of what laboratory tests
and other tests are included in the
composite rate and under what conditions
such tests may qualify for additional
payment in addition to the composite rate,
see the Medicare Benefit Policy Manual
Chapter 11, “End Stage Renal Disease
(ESRD),” and Chapter 8 of this manual.
Š Clinical diagnostic laboratory tests included
under the composite rate payment are paid
through the composite rate paid by the FI.
42

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Coding Laboratory Services Notes/Comments/Questions

Composite Rate Tests

43

Polling Question #2
“The Semicolon and Modifiers”

The placement of the semicolon in the

CPT description is an indication for the
need of a modifier?
[*1] True [*2] False

44

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Coding Laboratory Services Notes/Comments/Questions

National Correct Coding Initiative

Š The CMS National Correct Coding

Initiative (NCCI) edits provide many
specific instructions for use of CPT
modifiers used for laboratory services.
Š If an NCCI flag is reported on a claim,
consider that modifiers may be added to
remove the NCCI edit if the procedure is
distinct or unrelated to other procedures
performed on the same date.
45

Do these 2 Indented Codes Need a

Modifier?

46

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Coding Laboratory Services Notes/Comments/Questions

Do these 2 Indented Codes Need a

Modifier?

2 common
methods for
susceptibility
testing

47

Do these 2 Indented Codes Need a

Modifier?

48

AHIMA 2009 Audio Seminar Series 24

Coding Laboratory Services Notes/Comments/Questions

Modifier -59
Distinct Procedural Service
Š -59 is used to identify
procedures/services that are not
normally reported together, but are
appropriate under certain
circumstances.
Š -59 is used to designate instances
when distinct and separate multiple
services are provided to a patient on a
single date of service.
49

Modifier -59
Distinct Procedural Service

Š -59 is only to be used if no more

descriptive modifier is available
Š -59 is used for separate sessions or
patient encounters, or different
procedures.
Š -59 is used if the same procedure
using the same procedure code is used
for testing a different specimen (e.g.
aerobic culture of two independent
wound site specimens).
50

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Coding Laboratory Services Notes/Comments/Questions

Modifier -59
Distinct Procedural Service
Š -59 is NOT used when a test is ordered
and performed and additional related
procedures are necessary to provide or
confirm the result. These would be
considered part of the ordered test.
Š Example – A patient has an abnormal
test result and repeat performance of the
test is done to verify the result. Only one
unit of service of the test may be
reported.
51

Polling Question #3
“Use of Modifier -59”

Is modifier -59 used with flow

cytometry involving 88184 and 88185
x 3?
[*1] Yes
[*2] No

52

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Coding Laboratory Services Notes/Comments/Questions

Modifier -91
Repeat Clinical Diagnostic Test

Š -91 is used to identify repeat

performance of the same laboratory
test on the same day to obtain
subsequent (multiple) test results.
Š For example, if a second culture was
performed from the same wound site
on the same day, -91 is appended.

53

Modifier -91
Repeat Clinical Diagnostic Test

Š -91 is NOT used when tests are re-run

to confirm initial results due to testing
problems when a normal, one-time
reportable result is all that is required.
Š -91 is NOT used when other CPT codes
are available to describe series of
results (e.g. glucose tolerance tests,
evocative/suppression testing).

54

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Coding Laboratory Services Notes/Comments/Questions

-59 or -91 Case Study

A female patient is seen in the

outpatient laboratory for aerobic culture
of two sites of a single wound of the left
arm. The lab technologist obtains
independent specimens, one from the
proximal, and one from the distal wound
site. 87071 is coded x 2 for quantitative
aerobic bacterial culture. What modifier
is appended to the second code?
55

-59 or -91 Case Study

A male patient with hypokalemia had

multiple blood tests performed to check
potassium following potassium
replacement therapy. After the initial
potassium value, three subsequent
blood tests were performed on the same
date following the administration of
potassium to correct the patient’s
hypokalemic state. 84132 x 2 is coded
for serum potassium. What modifier is
appended to the second code?
56

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Coding Laboratory Services Notes/Comments/Questions

Modifier -90 Reference (Outside)

Laboratory
Š When laboratory procedures are
performed by a party other than the
treating or reporting physician, the
procedure may be identified by adding
modifier -90 to the usual procedure
number.
Š Although the physician is reporting
the performance of the test, the actual
testing component was a service from
a laboratory. 57

ESRD Modifiers: CD, CE, CF

Three pricing modifiers discreetly identify the
different payment situations for ESRD AMCC services.
The physician that orders the tests is responsible for
identifying the appropriate modifier when ordering
the test as follows:
● CD – AMCC test has been ordered by an ESRD
facility or MCP physician that is part of the
composite rate and is not separately billable
● CE – AMCC tests has been ordered by an ESRD
facility or MCP physician that is a composite rate
test but is beyond the normal frequency covered
under the rate and is separately reimbursable based
on medical necessity
58

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Coding Laboratory Services Notes/Comments/Questions

ESRD Modifiers: CD, CE, CF

● CF – AMCC tests has been ordered by an

ESRD facility or MCP physician that is not
part of the composite rate and is separately
billable
The ESRD clinical laboratory test identified
with modifiers “CD”, “CE” or “CF” may not
be billed as organ or disease panels. Upon
the effective date of this business
requirement, all ESRD clinical laboratory
test must be billed individually.
59

OIG Work Plan (FY 2009)

Š Compare pricing of individual tests vs.

profiles
Š Look for inappropriate unbundling of
profile tests
Š Analyze laboratory pricing policies for
End Stage Renal Disease services
Š Analyze Medicare/Medicaid laboratory
services for appropriate payments
60

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Coding Laboratory Services Notes/Comments/Questions

Why Doctors Order Lab Tests?

1. To Screen for Disease

2. To Diagnose a Disease/Condition
3. To Monitor an existing Disease
4. To Monitor a Therapeutic Drug

61

Information Available for

Each “Reason”
Š Screening
• No established diagnosis
• No signs or symptoms
Š Diagnosing
• There are signs and symptoms
Š Monitoring
• There is a diagnosis
• There is a treatment, care plan or
medication
62

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The Need for ABNs: Variable

Š To Screen for Disease

• ABN not necessary unless criteria not met
Š To Diagnose a Disease/Condition
• ABN not necessary if Signs/Symptoms given
Š To Monitor an existing Disease
• ABN not necessary if reason for test is
provided
Š To Monitor a Therapeutic Drug
• ABN not necessary w/V58.6x (V58.61 –
V58.69)
63

Screening Tests:
Legislative Provisions

Š See HCPCS Level II Book

• Lab
• PSA G0103
• PAP Smears G0123, G0143-148
• Fecal Occult G0328
Blood, Immunoassay
• Radiology
• Vaccines

64

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Beneficiary Notices Initiative (BNI)

65

The CMSR 131

66

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The CMSR 131

67

ABN Instructions and Options

68

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Guidelines for
Coding Blood Transfusions

Š Medicare Publication 100 -04

• Section 250….
Š The Order
Š The Product
Š The Cross-match and other testing
Š The Transfusion
Š Transfusion Reactions and Exceptions
69

Complete Billing of the

Blood Transfusion
Administration of
In Lab Testing The Blood Product
the Product

ABO, Rh, Antibody Screen –

(only 1 of each the above)
Bill 36430 once per
When Antibody Screens are Enter appropriate P code and # of
date of service
positive multiple units actually transfused
(NOT per unit given)
identification tests and
procedures are required

Crossmatch – depending on On occasion there is not a P code

CPT code 36430
the product ordered, bill a that completely describes the
includes all supplies,
crossmatch (select method) product. Add irradiation, splitting,
nursing time, room
for each unit tested – vol reduction as necessary.
fees (for OP).
whether transfused of not (CAUTION: Do not double bill!

Revenue Code 390 for most labs.

Revenue codes for lab may
Revenue Code 380- 38X is for
be 300 or 302. Follow FI Revenue Code 391
purchased products or when a
instructions.
hospital has its own donor center.
70

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Transfusion Medicine Case:

The Facts

The patient was admitted to Short Stay

unit for transfusion of 2 units of packed
red blood cells. The lab had a difficult
time finding compatible blood -
identifying an antibody and screening
10 units of blood to find 2 units that
were ultimately given.
What services and units of service can
be billed?
71

Transfusion Medicine Case:

The Answer
9 ABO (86900), RH (86901), Antibody Screen
(86850) 1 time for each CPT code (Rev Code
300/302)
9 Antibody Identification (86870) or Pretreatment
methods (86970- 86978) for each panel and for
each technique (Rev Code 300/302)
9 Screening for Compatible Units (86903 or 86904)
for all units screened (Rev Code 300/302)
9 Complete crossmatch (check with lab, could be
86920, 86921, and/or 86922) for each unit cross-
matched (not just the ones given). (Rev Code
300/302)
72

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NCCI Edits for Crossmatching

73

Transfusion Medicine Case:

The Answer
9 PRBC (P9016 if leukoreduced or
P9021 if not) for each unit given (Rev
Code 390)
9 Blood Administration (36430) 1/Day
(Rev Code 391)
9 Routine supplies are included in the
blood administration APC
9 E&M code is not used with 36430 if
that is the sole service
74

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Most Common “Missed” CPT Codes

in Lab: Microbiology
Š Stool Cultures: 87045 and 87046
• Most Labs use one plate for Salmonella and Shigella
which is coded with 87045
• Many Labs (esp in the South) test for multiple other
pathogens which require additional plates, such as
Vibrio, Yersinia, E. coli 0157, Campy, and more
Š Wound Cultures: 87070
• Many orders for wound cultures include “Anaerobic”
and “Aerobic” initial cultures as well as gram stains
Š Urine Cultures: 87088
• Best Practice = Every Urine culture (87088) has a
Colony Count (87086). Many labs only bill for one.
75

Aerobic and Anaerobic Cultures

with Blood Cultures

76

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Aerobic and Anaerobic Cultures

with Blood Cultures

77

Most Common “Missed” CPT Codes

in Lab: Microbiology
Š Serotyping colonies (87147)
• Many labs do not bill for “negative” testing
• Many labs do not bill for “each” antisera used

Š Identification tests (87077)

• Often a technologist suspects a pathogen but
the testing identifies a non-pathogen and the
charge is not submitted
• When multiple isolates are tested for
identification, the charge is only submitted for
one ID
Š E tests should be billed for “each” strip
(87181) 78

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Coding Laboratory Services Notes/Comments/Questions

Most Common “Missed” CPT Codes

in Lab: Microbiology
Š When doctors “add on” drugs for susceptibility
testing beyond the MIC, often the Kirby Bauer test
is not billed. (A modifier is required.) (87184 for KB,
87186 for MIC)
Š Many body fluid cultures require a concentration
step (i.e., centrifugation, millipore filters). Often
CPT code 87015 is missed.
Š There are numerous CCI edits for the various types
of cultures. Frequently, patients (think nursing
home patients or bronchial washings as an OP)
have more than one culture on the same date of
service. Without a modifier, only one culture will
pass CCI edits. 79

For More Information on Laboratory

Coding from CPT Assistant
See supplemental materials in the
Appendix for further CPT Assistant
citations on:
Š Basic metabolic panel
Š Chromosome studies
Š Mohs
Š Occult blood by peroxidase activity
Š Drug Testing for opiates and barbituates
Š H. pylori antibody rapid qualitative test
80

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For More Information on Laboratory

Coding from CPT Assistant

Š Immunology
Š Irradiation of blood products
Š Lactoferrin, fecal
Š Reproductive medicine procedures
Š Strep group B detection
Š Surgical pathology microdissection
Š Transfusion medicine
Š Microbiology for a variety of cultures
81

Resource/Reference List

Š American Hospital Association (“AHA”),

Coding Clinic. Chicago, Illinois
• Coding Clinic, Second Quarter 2006 Page: 4
Effective with discharges: July 15, 2006
• Coding Clinic, Fourth Quarter 2008 Page: 117
to 119 Effective with discharges: October
1,2008
• CC, 1st QTR 1990 Page 22
• CC, 3rd QTR 1999 Page 13-14
• CC, 1st QTR 2000 Page 3, 5-6
• CC, 2nd QTR 2006 Page 4
82

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Resource/Reference List

Š American Medical Association, CPT

Assistant. Chicago, Illinois
• CPT Assistant September 2003 Page: 5-7
• CPT Assistant, May 1997 Pages: 11-12
• CPT Assistant June 2008 Page: 157
• CPT Assistant, February 2006, Volume 16, Issue
2, pages 7-8, and page 16: Changes to
Pathology and Laboratory Part I
• CPT Assistant, March 2006, Volume 16, Issue 3,
pages 9 and 16: Changes to Pathology and
Laboratory Part II
83

Resource/Reference List

Š Center for Disease Control/National Center for

Disease Statistics. ICD-9-CM Official Guidelines
for Coding and Reporting, Effective October 1,
2008. Retrieved May 6 2009 from:
http://www.cdc.gov/nchs/datawh/ftpserv/ftpicd9/icdguide08.pdf

Š Centers for Medicare and Medicaid Services.

National Correct Coding Initiative Edits.
Retrieved May 6, 2009 from:
http://www.cms.hhs.gov/NationalCorrectCodInitEd/
Š U. S. Department of Health and Human
Services, Office of Inspector General. Work
Plan Fiscal Year 2009. Retrieved May 5,
2009 from:
http://www.oig.hhs.gov/
84

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Supplemental Material

Š CMS’ Internet Only Manuals

Publication 100
• Chapter 4 section 230 for Transfusion
Medicine
• Chapter 8 for ESRD Guidelines
• Chapter 16 for Lab Services

85

Other References:
Lab Websites
http://www.questdiagnostics.com/hcp/qtim/testMenuSearch.do

http://testcatalog.mayomedicallaboratories.com/

www.labcorp.com

http://www.cms.hhs.gov/manuals/downloads/clm104c16.pdf

86

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Audience Questions

Audio Seminar Discussion

Following today’s live seminar

Available to AHIMA members at
www.AHIMA.org
Click on Communities of Practice (CoP) – icon on top right
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Join the Coding Community

from your Personal Page under Community Discussions,
choose the Audio Seminar Forum
You will be able to:
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Coding Laboratory Services Notes/Comments/Questions

Become an AHIMA Member Today!

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member of AHIMA, please visit our
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AHIMA Audio Seminars

Visit our Web site

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While online, you can also register
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*Select audio seminars only

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Coding Laboratory Services Notes/Comments/Questions

Upcoming Seminars/Webinars

Coding for Respiratory Services

June 18, 2009
Physician Practice E&M Auditing
July 16, 2009
APC Revenue Cycle: Tips for Success
July 23, 2009

Thank you for joining us today!

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AHIMA 2009 Audio Seminar Series 46

Appendix

Resource/Reference List .......................................................................................48

CE Certificate Instructions

AHIMA 2009 Audio Seminar Series 47

Appendix

Resource/Reference List

http://www.cdc.gov/nchs/datawh/ftpserv/ftpicd9/icdguide08.pdf

http://www.cms.hhs.gov/manuals/downloads/clm104c16.pdf

http://www.cms.hhs.gov/NationalCorrectCodInitEd/

www.labcorp.com

http://www.oig.hhs.gov/

http://www.questdiagnostics.com/hcp/qtim/testMenuSearch.do

http://testcatalog.mayomedicallaboratories.com/

AHIMA 2009 Audio Seminar Series 48

 To receive your

CE Certificate

Please go to the AHIMA Web site

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click on the link to
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