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Making sense of the revised CPT codes.

This year's CPT code revisions were supposed to eliminate problems resulting from codes not keeping pace with lab technology, but errors in the revisions have provided new thorns equally capable of drawing blood. Here's how not to get stuck.

THE 1993 EDITION of Current Procedural Terminology (CPT) released by the American Medical Association (AMA) has changed dramatically the coding for lab services. The AMA update, which completely revised the 80,000 series codes in the Pathology and Laboratory Medicine section of the CPT, seeks to:

* Eliminate codes for obsolete service;

* Update nomenclature to reflect current technology and practice conventions; and

* Create new codes and descriptions for services that were previously not listed.

The laboratory industry, as well as the HCFA (Health Care Financing Administration)--the agency that administers the Medicare program--welcomed the revisions because the new CPT codes were supposed to solve many of the problems caused by coding that had not kept pace with lab technology.

The revised Pathology and Laboratory Medicine section contains more than 800 code deletions, additions, and revised descriptions. The extensive changes are focused primarily in the chemistry, toxicology, and immunology areas. Because of the exceptionally large number of changes and the complexity of AMA's editorial process, typographical errors occurred in the final edition of the 1993 CPT main book and the CPT "Pathology & Laboratory Medicine" medical specialty mini-book. Although the number of errors are small in comparison to the number of revisions, they are significant, and unless identified, can cause errors in coding services. The errors include codes and descriptions mistakenly deleted, codes cross-walked to inappropriate codes, and incorrect descriptions. The AMA has published an errata in the summer edition of its newsletter, CPT Assistant.

* Delay in implementation. The renumbering of certain codes and the condensing of multiple, but related, codes into one code required HCFA to recalculate the national limitation amounts (NLA) for the clinical laboratory fee schedule. Because of this, HCFA initially delayed implementation of the 1993 CPT codes for laboratories until April 1, 1993. This date was later extended to May 1, 1993, with a 90-day grace period through July 31, 1993. During the grace period, laboratories could code services with either the 1992 or 1993 CPT codes. Services provided prior to May 1, 1993, were to use the 1992 codes, with payment based on the 1992 clinical laboratory fee schedule with the 2% stipulated increase.

In preparation for the May 1 implementation date, HCFA recalculated the NLAs based on 1992 fees submitted by the Medicare carriers. On March 25, 1993, the recalculated NLAs were distributed to the carriers. The NLAs were carefully analyzed by consultants and suppliers within the industry and determined to be in error. The majority of the payment amounts were reduced, with many lowered by as much as 7% to 12%. Stanley H. Beck, director of healthcare economics, Abbott Laboratories, who first identified lower payment amounts, calculated that if the incorrect NLAs were implemented, they would have taken more than $160 million out of the clinical laboratory Part B payment amount for fiscal year 1994. For example, the NLA for the 80019 chemistry profile code was cut 6.9%, HDL cholesterol was cut 10.7%, and hemogram (CBC) was cut 12%.

The industry was quick to question HCFA's methodology, which prompted HCFA to send a letter on May 12, 1993, to all Medicare contractors acknowledging that an error had been made. The letter instructed all Medicare carriers and fiscal intermediaries to implement the following payment procedures for claims filed between May 1, 1993, and July 31, 1993:

* All fees and NLAs for codes that were not revised should be paid applying the 1992 limits with the 2% adjustment.

* For all CPT codes that were revised, all contractors, carriers, and fiscal intermediaries should use the incorrect NLAs furnished on March 25, 1993, until HCFA issues recalculated NLAs.

The contractors also were instructed to notify providers and appropriate state and local medical and professional societies of the error and issue special newsletters or bulletins to all providers of laboratory services informing them:

* Of the errors in the March NLAs;

* Of the basis of payment to be used until the NLAs were corrected; and

* That contractors will be making mass adjustments on any claims processed with the incorrect NLAs.

HCFA's suggested language included the statement: "By early August, we |the carrier or fiscal intermediary~ will review all claims |for revised and any applicable revised codes~ and make necessary adjustments en masse." The adjustments are to be made within 60 days of HCFA reissuing the NLAs. It is extremely difficult, however, for most providers to keep track of the amount of underpayment they received from Medicare on claims submitted for services between May 1, 1993, and July 31, 1993, or to calculate accurately the dollar amount of the adjustment Medicare is scheduled to "refund" to them sometime after August 1, 1993.

* Gap-filled codes. To further add to the confusion for providers not fully versed in Medicare billing and payment policies, the local carriers are to determine payment amounts for certain new codes that do not have prior fee history at the local carrier level, such as the new prostate-specific antigen (PSA) code 84153. Medicare requires that the local carrier establish an allowance for new codes based on defined criteria for determining reasonable charges. The carrier must consider:

* The customary charges for similar services generally made by the physician or other person furnishing such services; and

* The prevailing charge in the locality for similar services.

The law also provides that the reasonable charge for a service may not exceed the charge applicable for a comparable service.

Prior to May 1, 1993, laboratories billed PSA using the generic tumor antigen code, 86316. The 1992 NLA for code 86316 was $31.90. The majority of services billed to 86316 in 1992 were, more than likely, for PSA tests rather than for CA125; therefore, the local carrier should establish a fee for PSA code 84153 that is comparable to what it was paying for code 86316 in 1992.

In some cases, HCFA is directing the level of allowance that should be established at the local level. In an April 8, 1993 memorandum, HCFA informed the regional administrators for Medicare and Medicaid that "code 83518 |immunoassay, for analyte other than antibody, qualitative or semiquantitative~ must be gap-filled, and that this code describes quick or low technology (e.g., reagent strip or dipstick tests) immunoassays, and should be priced accordingly."

That statement is not entirely correct. It is correct when billing the code for a quick screen (reagent strip or dipstick test) for drugs of abuse performed in the emergency room. It is not correct, however, when testing for antigens such as Chlamydia, Cryptosporidium, Giardia, and other antigen test procedures. These procedures require a higher level of precision in performing and interpreting test results and a great deal more labor time than a reagent strip or dipstick test. If the local carriers price code 83518 "low," as instructed by HCFA, laboratories may have difficulty in covering the cost of most antigen testing.

Having only one generic code for antigen testing may be an oversight of the AMA CPT editorial panel. AMA recognizes that all antibody immunoassay testing technology is not equivalent to reagent strips or "quick screens." If you compared the antigen description to the descriptions for the antibody codes, it would appear that specifying code 83518 for quick screen technology is not appropriate.

AMA has developed three separate coding options for antibody testing by immunoassays:

* By specific virus, codes 86602-86793.

* When a specific virus is not listed, generic code 86790 ("Antibody; virus, not elsewhere specified").

* When a low technology or "quick screen" test is performed, code 86318 ("Immunoassay to infectious agent antibody, qualitative or semi-quantitative--e.g., reagent strip").

The same options should be available for coding immunoassay antigen testing procedures as are available for coding the various immunoassay antibody procedures.

Laboratory managers need access to the 1993 clinical laboratory fee schedule, available from their carrier or fiscal intermediary, to determine whether the fees listed for the gap-filled codes are realistic. If they appear unreasonably low, laboratories should inquire as to what data were used to establish the fee; the information is available to providers under the Freedom of Information Act. The appropriate time to work with the carrier in determining price is when pricing is to be determined at the local level. HCFA has indicated that there are more than 90 codes that will be gap-filled.

* Matching the code to the service. The format of the CPT requires a thorough knowledge and understanding of laboratory procedures in order to be able to select the proper code. The coder in a billing or medical records department cannot correctly code the laboratory's procedures without the technical input of a laboratory specialist well versed in the specific procedures and methodologies being used in the individual laboratory.

Applying the correct codes in 1993 is even more difficult because of the considerable number of errors in the Pathology and Laboratory Medicine section of the 1993 CPT. For example, a coder unfamiliar with laboratory test procedures would not be able to identify the error in the following description.

83916 Oligoclonal immunoglobulin (oligoclonal band) 83918 Quantitative

The word "quantitative" appears to refer to a unique portion of 83916, but any laboratorian would recognize the error. CPT code 83917 was deleted in 1993, and it contained the common portion of 83918, which is "Organic acids, quantitative."

For some areas, such as chemistry, the 1993 CPT's instructions require the coder to be familiar with the specific test methodology. Codes listed in the chemistry section are for quantitative procedures unless otherwise specified. Selecting the appropriate code is dependent on knowing the procedure methodology. Lack of the appropriate knowledge could have a significant financial impact. A coder unfamiliar with the laboratory's test procedures may be unable to determine the correct code.

The AMA's listing of a code in the CPT does not mean it is automatically covered for payment by Medicare. HCFA has instructed its Medicare contractors not to pay on the new CPT code 80103, "Tissue preparation for drug analysis." Medicare does not recognize this code because the service is usually associated with an autopsy.

It is also generally expected that HCFA will not continue to pay on code 36415 used for billing the venipuncture draw fee because the revised description now includes the wording "or finger/heel/ear stick," and Medicare does not pay for finger, heel, or ear sticks. HCFA stated it intends to make a "Q" code available for billing the venipuncture, but at the time of this writing, this has not occurred. According to Texas Blue Cross and Blue Shield, however, Medicare in the Texas area is no longer paying on code 36415 and has instructed providers and suppliers to bill the draw fee using a "P" code.

* Major code changes. Among the hundreds of code changes, there are many that can be considered major. Here is a summary of the more significant ones:

Automated multichannel tests. The 1993 CPT lists 19 analytes. Albumin/globulin ratio and globulin have been deleted from the list and the descriptions for SGOT and SGPT have been updated to reflect current scientific terminology, AST and ALT, respectively. Individual Medicare carriers have the option to expand the automated list, and many are including CK, GGT, and triglycerides. Some carriers, including Pennsylvania, Virginia, and Massachusetts, also require procedure code 80002 to report two or more automated multichannel tests on the same patient on the same day. Other carriers do not require billing of the automated multichannel codes when performing less than three tests on the same patient on the same day.

Organ- or disease-oriented panels. Twenty-two panel codes were deleted, and the remaining nine panels have the test components defined. All component testing must be performed to bill a panel code. Tests performed in addition to the listed components are to be billed separately. If, however, a laboratory bills code 80058, the hepatic panel that consists of five automated tests, and also bills another automated code, such as 80007, the carrier or fiscal intermediary has been instructed by HCFA to regroup the billed codes and price based on the total number of automatable tests.

Prior to the publication of the 1993 CPT, the organ or disease panels did not have national limitation amounts because the test components were not defined. Payment levels are now based on the NLAs of each test included in the panel.

Drug testing. This is a new section containing specific instructions regarding coding for drugs of abuse. The CPT lists drugs by classes, and the coding of the tests is based on the procedure--not on the method or analyte. There are four codes listed for drug testing. For screening purposes, the code selected for billing, 80100 or 80101, is based on whether the procedure tests for multiple drug classes or a single drug class. If an actual "quantitation" of the confirmed drug(s) is performed, this would be reported using the code(s) for the specific analyte listed in the Chemistry or Therapeutic Drug Assays sections.

Therapeutic drug assays. This new subheading replaces the former Therapeutic Drug Monitoring section and follows the Drug Testing section in the 1993 CPT. The analytes listed in the earlier editions have been recoded and a few new analytes have been added, such as cyclosporine; dipropylacetic acid; phenytoin, free; and procainamide, with metabolites. Three antimicrobials--amikacin, gentamicin, and tobramycin--are also included in the new listing. A new miscellaneous code, 80299, "Quantitation of drug, not elsewhere specified," has been added and replaces code 80031.

National limitation amounts established for the drug testing and therapeutic drug assay codes are based on previous fee data. Not all new codes will be gap-filled. If there are pricing data available that can be cross-walked to the new code, these will be used rather than having the local carrier establish a fee.

Chemistry. The introductory guidelines to this section contain three important notes regarding coding service:

* If the source is not stated, the material for testing is from any source;

* Examinations are quantitative unless specified; and

* Information derived from mathematical calculations, such as the free thyroxine index (|T.sub.7~), is considered part of the test procedure and is not a separately reportable service.

Many of the codes in this section have been deleted and the former codes collapsed into one or more codes. HCFA used a weighted average to determine the national limitation amount for the remaining or related new code. For example, the NLA for calcium was derived from the weighted average of four 1992 calcium codes: 82310, 82315, 82320, and 82325.

Molecular diagnostics. This is a new subsection within Chemistry that contains five new codes. Each of these codes describes a procedure rather than an analyte. Designating coding by procedure rather than analyte will allow for more flexibility as the technology matures and the procedures change.

The instructions in the CPT are to code separately for each procedure used in the analysis. HCFA had given the Medicare contractor specific payment instructions regarding these codes. According to HCFA, "multiple billings of these codes may be made if multiple services are performed." HCFA further states: "Code 83912 is to be used only for the interpretation and report of these studies. Although only one interpretation and report are performed in a given study . . . |a~ study could consist of one probe or 20 or more." Therefore, HCFA has priced 83912 at one-fifth the former price and will allow for multiple billings of 83912 up to the total number of probes performed.

Hematology. Over the last several years, the CPT has been moving the histochemical staining procedures into the Surgical Pathology section. As a result, the stains performed in the clinical laboratory sections have not had a code for billing the technical procedure. The 1993 CPT continues this trend with the deletion of code 85109 for the staining and preparation of bone marrow smears. Hematology departments that stain and prepare bone marrow slides for the pathologist will not be able to bill for this portion of the procedure with a separate code.

A new code, 85008, for "Blood count, manual blood smear examination without differential parameters" can be used. The laboratory now has a code for billing slides that are manually reviewed, but this will require generating a bill from the laboratory after the service is performed. Codes 85670 and 85675 for the thrombin time and titer were deleted in error, but HCFA has retained these codes on the fee schedules.

Immunology. This section contains more than 70 new antibody-specific codes, 86602 through 86793. It is important to note that this listing is preceded by detailed guidelines regarding the use of these codes. Many procedures can be coded with increased specificity for virus, family, genus, species, or type. When multiple tests are done, it is appropriate to code each as a separate service. All except six of the codes will have the pricing determined at the local carrier level.

Transfusion medicine. This is a new subsection within Immunology that consists of 35 new codes. Many of these codes were moved from other sections of Immunology and relocated into Transfusion Medicine. The descriptions for a number of these codes have been revised.

The coder must keep in mind that even though a CPT code is available, certain codes within the transfusion medicine section are "transfusion related." Therefore, these codes are "not subject to the fee schedule limitations" and should not be billed using a CPT. They are paid on the basis of reasonable charges. Codes that are not transfusion related should be billed using a CPT code. They are paid from the clinical laboratory fee schedule.

* Summary. The coding, billing, and pricing of laboratory services is extremely complex. HCFA and the local Medicare carrier strive to make careful determinations of reasonable charges and fee schedule amounts that are equitable both to those rendering the services and to those paying for the services. As demonstrated above with the CPT immunoassay antigen code, 83518, however, to correctly code, bill, and price laboratory services requires a technical understanding of clinical laboratory technology. While most Medicare medical directors do seek input from the provider community through an advisory committee, these committees often are not well versed in laboratory technology or in the Medicare regulations for billing laboratory services. Each of these factors impacts on the other.

To apply the CPT codes correctly to your laboratory services, you need a general knowledge and understanding of the Medicare payment policies, the various coding systems, the technology, and the carrier/fiscal intermediary coding variations. Coding services for the laboratory and other technical departments requires the coder to work with the department to define the services, methods, instrumentation, and practices that impact the individual test procedures. Technical input is critical to accurate coding.


Health Care Financing Administration Memorandum, BPO-042, March 26, 1993.

Health Care Financing Administration Memorandum, FQA-542, April 8, 1993.

Health Care Financing Administration Memorandum, Letter to all Medicare contractors, May 12, 1993.

Medicare Part B Carriers Manual 5000, 5002, 5114.1.

Physicians' Current Procedural Terminology (CPT). Chicago, Ill: American Medical Association; 1993: 464-546.

Logue is a partner and Dettwyler is a senior coding analyst of Health Systems Concepts, Inc., health care management consultants based in Longwood, Fla.
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No portion of this article can be reproduced without the express written permission from the copyright holder.
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Title Annotation:current procedural terminology
Author:Logue, L. Joan; Dettwyler, William K.
Publication:Medical Laboratory Observer
Date:Aug 1, 1993
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