Hospital Billing for Lab and Path Procedures
Chapter 6 (p. 185)Pathology and Laboratory ServicesPage | 1
Hospital Billing for Lab and Path Procedures
Chargemaster automates billing of lab and path services.
Clinical Lab (no physician signing off on reports) is accredited separately from Pathology Lab (with physician signing off on reports)
Some insurance co's allow providers to bill the lab portion of the procedure even tho it is being sent out. The reimbursement is then forwarded to the lab when it is received by the provider.
Usually providers only bill E/M and let the lab file claim for the lab part.
Physician can code and bill for the venipuncture (drawing of the blood).
Physician Billing
36415 vs 36600 = Vein vs Artery
99195 Phlebotomy, therapeutic
Just bill for the drawing, not for the lab work, usually.
Quantitative/Qualitative Studies
Qualitative: is that drug there? (1st)
Quantitative: How much of it is there? (2nd)
Drug Screens (CPT p. 452)
80100 Multiple drug class, chromat.
80101 Single drug class
80104 Multiple drug classes, non-chromat.
Physician orders drug screen: See if any drug present (multiple) 80100
Physician orders specific drug tests: amphetamines, alcohol
(single) use as many times as needed for each test.
Pt presents to the ER in a coma. Family members provide Hx of anxiety and depression under Tx w/prescription meds. Physician orders drug screen for alcohol, barbiturates, benzodiazepines, phenothiazines,and tricyclic antidepressants. The lab performs a single drug class screening for each analyte by means of amino acid methods on a random access analyzer.
80101 + 80101 + 80101 + 80101 + 80101
80102 If they have to do a drug recheck (screen it again later in the day) Qualitative to confirm
Quantitative to see how much is there: Look at
Therapeutic Drug Assays(drugs used for therapeutic reasons: 80154 Benzodiazepines
Chemistryfor all other drugs
Modifiers
-91 Repeat lab (of exact same thing). Specific to Clinical Lab.
Review
Drug Screen Order: 80100
Drug Screen for barbiturates, opiates, and methamphetamines: 80101 + 80101 + 80101 (no -91 bcs there is not a repeat of the same drug or -59 bcs "each drug class" in narrative means the same thing)
Modifiers: -91 is used only forrepeatdiagnostic clinical lab tests. Not for Pathology which is on tissue.
Panels
Groupings of lab tests
80048 All these tests are included in 80053 with more tests added. You can group tests into these panels if they fit and then code separately the drugs that are not included.
If Comprehensive Metabolic Panel was run and found glucose was high, later in the day (same DOS) they may run the glucose 82947-
80053 + 82947-91
CMS receives the above claim and unbundle the panels into separate drug codes. Important to put the 82947-91 above because the glucose will show up on CMS' side with 2 glucose tests on the same day (one of them part of the panel). Your scrubber may not catch this if you forget to put -91 on the code, but CMS's scrubber will.
Examples:
Dr. performs a lipid panel on automated equip. in his office. The battery of tests include: HDL, Total serum cholesterol, triglycerides, and quantitated glucose.
80061 + 82947
Dr. performs a metabolic panel on automated equip. in office. The battery of tests include: serum CO2, Chloride, Creatinine, Glucose, K, Na, BUN
80051 + 82947 + 82565 + 84520
Evocative/Suppression Testing
More panels that are done less often than the previous ones. These are very specific to the tests to elicit a specific response.
Urinalysis and Chemistry
Look to see if qualitative or quantitative.
Chemistry includes urine, blood, feces, sputum. These are usually Quantitative. Read narratives closely to be sure to get the correct code. The same test may need to be run for pts on several of these mediums.
If narrative doesn't say it is specific to urine or blood, but you need to use the same code if you run it on each of the different mediums (source). You will need -59 to show they are distinctly different tests.
Hematology and Coagulation (p. 491) (85002-85999)
CBC's and clotting time. Need to know the technique and the method used. Know the lab: Automated or not? Sometimes they need to do a manual count even if they usually do automated.
Blood banking is not here. There is a separate Transfusion section (86850-86999) (CPT p. 499)
Molecular Pathology
Really complicated area to code. May need to consult w/lab tech to help translate what is being done. Make sure they have a copy of the current CPT manual.
Surgical Pathology
Compare:
Consultations (Clinical Pathology) (CPT p. 454)
80500-02 These are the normal physician consultations, but without review of Pt's Hx and medical records. (face-to-face).
to
(CPT p. 513)
(88321-88325) These are for when specimens or slides are sent off to a place like MAYO for 2nd opinion. The pathologist needs a 2nd opinion. This includes a review of Pt's Hx and medical records.
Levels I, II, III, IV, V, and VI (88300-88309)
These determinations are driven by where the specimen came from.
Fibroid Tumor (Leiomyoma) = neoplasm. Could be benign or malignant. Uterus level V (non-neoplastic) or VI(neoplastic)
If an edit is pulled (saying one is a component of the other) when putting thru two codes for the same level, only then modify with -59. Ex: Colon and Gallbladder, levelIII.
See Example 3 on pg. 190: Make sure each is separate on the pathology report. If you need a modifier, use -59 because it is a separate specimen, not a repeat.
Frozen Sections (Pathology consult during Surgery)
(88329-88334) Be aware colored sutures are used to differentiate btwn specimens. Don't code these.
Example:
Code for Pathology during surgery88329
+ code for frozen section88331/3
+ code for each additional frozen section 88332/4
+ code for level 88302-88309
Example: Gross & Microscopic portions of path report are often done by different physicians.
Ans: The facility codes it all together. (Technical component)
If physician is employed by hospital, then the hospital submits profees together and then disseminates to physicians.
If each physician submits a claim it would be reduced (52)
Microbiology (87040)
Blood cultures often done twice in succession.
If sepsis is suspected, they will do blood cultures x 2 every time. Here they are checking for contaminants. The 1st stick goes thru skin and may pick up contaminant. The 2nd test is the clean sample.
87086 Urine culture (no growth) attempt(s)
otherwise (instead of)
87088 Urine culture (with growth) to identify the growth(s).
If growing E coli and Enterococcus
80788 + 80788
Here there is no modifier bcs of "each" in narrative.
88141-143 Pap Smears
Who reads the results determines the code used.
..141 is used if physician reads it. (not often)
..142 is used if the staff read it.
If staff member sees something, physician rescreens it, use ..143.
If staff routinely read test results, the physician should be doing some quality control and randomly check the results. When the physician reads the test in this case the code should not be changed (from the staff code).
Fine Needle Aspiration (2+ codes) includes code for procedure of pulling the fluid and another code for evaluation of the fluid:
10021 without imaging guidance or
+ 88173 Cytopathology
10022 with imaging guidance
+ 88173 Cytopathology
+ Imaging guidance (CPT p. 416-418)
If the cyto on both above was a frozen section, then 88172 would be included above on both.
Billing:
Facility claim (technical component only)
Radiologist for imaging guidance (-26)
Pathologist for looking at cytopathology (-26)