DEPARTMENT: Governmental Operations Support / POLICY DESCRIPTION: BILLING - Hematology Procedures
PAGE:1 of 5 / REPLACES POLICY DATED: Jan. 16, 1998; March 1, 1999
APPROVED: June 19, 2001 / RETIRED:
EFFECTIVE DATE: August 1, 2001 / REFERENCE NUMBER: GOS.LAB.002
SCOPE: All Company-affiliated facilities performing and/or billing laboratory services. Specifically, the following departments:
Business Office Nursing
Admitting/Registration Laboratory
Finance Health Information Management Services
Administration Utilization Review Management
Revenue Integrity Medicare Service Centers
Patient Account Services
PURPOSE: To establish guidelines for billing hematology services in accordance with Medicare, Medicaid, and other federally-funded payer requirements. Hematology services must not be “unbundled” (i.e., the use of two or more CPT billing codes in lieu of one inclusive code), double billed, or improperly submitted (i.e., for tests not ordered, for tests not medically necessary, etc.)
POLICY: Hematology services billed to a federally-funded program must be based on a written order and be medically necessary. Hematology procedures which include three or more components must not be “unbundled” into individual procedures. Repeated laboratory tests, including overlapping components of panels, may be billed when the tests are medically necessary, which is indicated by reporting the 91 modifier.
The 91 modifier may only be reported when in the course of treating a patient, it is necessary to repeat the same laboratory test on the same day to obtain subsequent test results. This modifier may not be reported when tests are rerun to confirm initial results; due to testing problems with specimens or equipment; or for any other reason when a normal, one-time, reportable result is all that is required. This modifier may not be used when other code(s) describe a series of test results (e.g., glucose tolerance tests, evocative/suppression testing). If a payer does not recognize/accept the 91 modifier, repeated laboratory tests may not be billed.
PROCEDURE: The following steps must be performed when billing hematology services to Medicare and other federally-funded programs.
IMPLEMENTATION
  1. Facility personnel must review and verify applicable entries are present in the facility chargemaster and appropriately tied to the related Laboratory and Order Entry masterfiles/dictionaries as follows:
  1. Assign CPT /HCPCS codes listed below and attach revenue code 305 in accordance with the Company Standard Laboratory Chargemaster.
Components:
CPT Code AMA Description
85007 Blood count; manual differential WBC count (includes RBC morphology and platelet estimation)
85009 Blood count; differential WBC count, buffy coat
85013 Blood count; spun hematocrit
85014 Blood count; other than spun hematocrit
85018 Blood count; hemoglobin
85041 Blood count; red blood cell (RBC) only
85048 Blood count; white blood cell (WBC)
85595 Platelet; automated count
Panels:
CPT Code AMA Description
85021 Blood count; hemogram, automated (RBC, WBC, Hgb, Hct, and indices only)
85022 Blood count; hemogram, automated, and manual differential WBC count (CBC)
85023 Blood count; hemogram and platelet count, automated, and manual differential WBC count (CBC)
85024 Blood count; hemogram and platelet count, automated, and automated partial differential WBC count (CBC)
85025 Blood count; hemogram and platelet count, automated, and automated complete differential WBC count (CBC)
85027 Blood count; hemogram and platelet count, automated
85031 Blood count; hemogram, manual, complete CBC (RBC, WBC, Hgb, Hct, differential and indices)
  1. Three or more components must be bundled to the appropriate panel. Therefore, remove charge explosions from hematology panels which contain three or more components. Two or fewer components may be ordered as a “panel” but must be billed as individual components, e.g., H & H (Hemoglobin and Hematocrit).
  1. Business office personnel must verify that edits are present in the electronic billing system which:
  1. Bundle components to the panel level when three or more components are charged on the same patient on the same date of service.
  2. Identify outpatient claims for federally funded payers which include repeated hematology panels and/or components performed for the same patient on one date of service.
  1. Laboratory and business office personnel must educate all staff associates responsible for ordering,
charging, or billing laboratory services on the contents of this policy.
  1. Monitoring activities should be completed in accordance with the Billing – Monitoring Policy, GOS.GEN.001.
  1. Business office personnel must identify intermediary interpretations which vary from the interpretations in this policy. Specific documentation from the intermediary related to the variance(s) must be obtained and provided to the Billing Help Line at 1-888-735-3669.
DAILY
  1. It is recommended but not required that laboratory personnel review daily charge reports (e.g., Ancillary Charge Report, NPR charge reports, etc.) to verify compliance with this policy as follows:
  1. Duplicate hematology components which are not medically necessary are not billed to federally-funded programs.
  2. Repeated hematology panels and components are billed to federally-funded programs only when medically necessary.
  3. Three or more hematology components are bundled to the appropriate panel defined as follows:
85021 85022 85023 85024 85025 85027 85031
85007 85007 85007 85007 85007
85009 85009 85009 85009 85009 85009
85013(14) 85013(14) 85013(14) 85013(14) 85013(14)85013(14) 85013
85018 85018 85018 85018 85018 85018 85018
85041 85041 85041 85041 85041 85041 85041
85048 85048 85048 85048 85048 85048 85048
85595 85595 85595 85595 85595
Any exceptions noted on the daily charge reports should be corrected on the individual patient accounts. This will ensure that your accounts receivable system remains updated with actual billing data.
  1. Business office personnel must review electronic billing edit / error reports daily and perform the following:
a)Bundle hematology components into the appropriate panel when three or more are billed.
b)Identify presence of more than one hematology panel and determine if documentation is present to support medical necessity of repeated panels.
i)Append the 91 modifier to repeated tests/panels which are medically necessary.
ii)Eliminate repeated tests/panels which are not medically necessary. Modify number of units and related charges in the electronic billing vendor system to reflect the appropriate charge and CPT for the panel being billed.
c)It is recommended but not required to modify the number of units and related charges in the Accounts Receivable system to match the corrected claim in electronic billing system. (Note: Utilize ancillary charge codes rather than correcting claims with adjustment codes. Corrections made subsequent to final bill should be processed through your patient accounting system late charge cycles.) This will ensure that your accounts receivable system remains updated with actual billing data.
The Facility Ethics and Compliance Committee is responsible for implementation of this policy within the facility.
EXAMPLES:
  1. A. Doctor orders CBC with Diff.
B. The CBC is performed on a automated system and you report complete CBC with platelet, indices and auto diff.
BILL: CPT code 85025 (Automated Hemogram with Platelet and auto diff)
  1. A. Doctor orders CBC no diff (Hemogram).
B. You report results, some of which are abnormal.
C. Doctor then orders complete CBC w/ diff on the same sample.
D. You report CBC, platelet, indices, and diff (performed on automated system).
BILL: CPT code 85025 (Automated Hemogram with Platelet and auto diff)
  1. A. Doctor orders CBC w/ diff.
B. You perform test on an automated system that includes indices, platelets.
C. You perform a spun hematocrit to confirm a discrepancy between the hemoglobin and hematocrit values.
BILL: CPT code 85025 (Automated Hemogram with Platelet and auto diff)
  1. A. Doctor orders Hemoglobin and Hematocrit and a White Blood Count.
B. You perform these three tests on an automated system.
BILL: CPT code 85021 (Automated Hemogram)
  1. A. Doctor orders a CBC with diff.
B. You perform this on an automated system. (85025)
C. Manual Diff is performed due to abnormal values.(85007)
D. You report CBC, Platelet, Indices, and Manual Diff results.
BILL: CPT code 85023 (Automated Hemogram with Platelet and manual diff )
Special Considerations:
DO NOT CHARGE FOR services reported as a result of a calculation. This includes CPT 85029 and 85030. CPT codes 85029 and 85030 have been deleted from the AMA CPT Manual.
DO NOT CHARGE FOR both manual and automated differential on the same patient for the same date of service.
DEFINITION:
Encounter: Each date of service.
REFERENCES:
Medicare Reimbursement Manual for Clinical Laboratory Issues; National Edition, 1997. Washington G-2 Reports, Washington, D.C.
Medicare Hospital Manual, U.S. Dept. of Health and Human Services, CMS (formerly known as HCFA) – Pub. 10 thru T703, Rev. 7/97. Billing Procedures Section 437.
National Correct Coding Policy Manual for Part B Carriers, Third Edition, 1997. U.S. Dept. of Commerce.
U.S. Department of Justice, Subpoena dated December 27, 1996 (Exhibit A regarding: Outpatient Laboratory Billings To Medicare and Medicaid Programs)

7/2001