GeneralCPTCodingRulesforLaboratoryProcedures

WhenreportingCPTcodesforindividualclinicallaboratoryprocedures,thefollowingrulesapply:

1.Selectthecodethatmostaccuratelyidentifiestheservicebeingperformed.ThelistingofaprocedureunderaparticularspecialtyintheCPTdoesnotrestrictitsusetoaspecificspecialty.

2.Whenaprocedureforaspecificanalyteisnotlisted,usethemethodcodethatmostaccuratelyidentifiestheprocedureused.Asalastresortuseanunlistedservicecode(thoseendingin99)plusappropriatedescriptionoftheprocedure.

3.Thesamecodemaybeusedmultipletimeswhenseparateanddistinctproceduresareusedtoobtainandreportseparateanddistinctresults.

4.Unlessotherwisespecified,laboratoryproceduresareassumedtobequantitative.

5.Thematerialexaminedmaybefromanysourceunlessotherwisespecifiedinthecodedescriptor.

6.Anymethodofanalysismaybeemployedunlessotherwisespecifiedinthecodedescriptor.

7.Clinicalinformationderivedfromtestresultsbymathematicalcalculationisconsideredapartofthetestprocedureandisnotcodedorreimbursedseparately.

CPTandHCPCSCodeModifiers

CPTandHCPCScodemodifiersaretwodigitcodesaddedtothebasicfive-digitCPTcode.Thefollowingmodifiersareusedtodescribeunusualcircumstancesorprovideadditionalinformationregardingelectrophoresisprocedures.HCPCSCodeModifiersarecreatedbyCMS(ratherthantheAMA)todescribesituationsnotcoveredintheCPT.

-59DistinctProceduralService:ThisCPTcodemodifierisusedtoindicateatestorservicewhich,eventhoughtheCPTcodeisthesame,isadistinctanddifferenttestorprocedure.

Example1:ApolipoproteinAandB1aredeterminedonthesamedateofservice.

ThesameCPTcode(82172,Apolipoprotein,each)isusedtoreportbothassays.Toavoidadenialofthesecondcodeasa“duplicatedservice”,itshouldbereportedusingthe–59modifier.Thetwocodessubmittedforpaymentwouldbe82172,forApolipoprotienA,and82172-59forApolipoproteinB1.

Example2:ForaMultipleMyelomapatientwithanIgGKappabandontheImmunofixationanddeterminedtobetakingthedrugdaratumumab,inthiscase,the-59isapplicableforthesecondImmunofixation(86334)whichwillbeadistinctanddifferenttest(Hydrashift2/4daratumumabImmunofixation).

-26ProfessionalComponent:ThisCPTcodemodifierisusedtoidentifyaphysiciancomponentofatest(suchasinterpretation)whenitisreportedseparately.Similarlyintheexample2above,the-26

modifier(interpretationofthesecond,HydrashiftImmunofixation)wouldbeapplicablewheninterpretationisperformed.

-90Reference(Outside)Laboratory:ThisCPTcodemodifierisonlyusedbyhospitalorreferencelaboratoriestoidentifytestssenttootherlaboratories.

-GAAdvancedBeneficiaryNotice(ABN)onFile:ThisHCPCScodemodifierisusedtoindicatethattheproviderhasnotifiedaMedicarepatientthatthetestperformedmaynotbereimbursedbyMedicareandmaybebilledtothepatient.ABN’smustbeobtainedbyaproviderandsignedbythepatientifthepatientistobebilledfortestsorotherservicesnotcoveredbyMedicare.

CPTCodesAssociatedwithElectrophoreticProcedures

ProteinElectrophoresis:

84165Protein,electrophoreticfractionationandquantification,serum

84166Protein,electrophoreticfractionationandquantification,otherfluidswithconcentration(eg,urine,CSF)

83916Oligoclonalimmune,(oligoclonalbands)

84181Protein,Westernblot,withinterpretationandreport

84182Protein,Westernblot,withimmunologicalprobeforbandidentification,each

TotalProteinDeterminations:

84155Totalprotein,exceptrefractometric

84160Totalprotein,refractometric

ImmunofixationAssays

86334Immunofixationelectrophoresis,serum

86335Immunofixationelectrophoresis,otherfluidswithconcentration

CPTcode86334isusedforanyspecimennotrequiringconcentration,86335isusedforanyspecimen(includingserum)thatrequiresconcentration.

HemoglobinAssays

83020Hemoglobinfractionationandquantitation,electrophoresis

83036Hemoglobin,glycosylated,A1c

IsoenzymeAssays

82552CKisoenzymes

83625LDHisoenzymes,separationandquantitation

84080Alkalinephosphataseisoenzymes

LipoproteinAssays

83715Lipoprotein,blood,electrophoreticseparationandquantitation

83716Lipoprotein,blood,highresolutionfractionationandquantitationoflipoproteincholesterols(eg,electrophoresis,nuclearmagneticresonance,ultracentrifugation)

83718Lipoprotein,directmeasurement,HDLcholesterol

83719Lipoprotein,directmeasurement,VLDLcholesterol

83721Lipoprotein,directmeasurement,LDLcholesterol

82172Apolipoprotein,each

SpecimenCollectionCodes

Medicareandmostotherpayersallowaseparatespecimencollectionchargefordrawingorcollectingspecimensbyvenipunctureorcatheterizationwhetherornotthespecimenisprocessedonsiteorreferredtoanotherlaboratoryforanalysis.Onlyonecollectionfeeisallowedforeachpatientencounter,eventhoughmultiplespecimensmaybecollected.

ThefollowingCPTcodesareusedtoreporttheroutinecollectionofblood.

36415Collectionofvenousbloodbyvenipuncture

36416Collectionofcapillarybloodspecimen(eg,finger,heel,earstick)

CPTcode36415codeisusedtoreportroutinevenipunctures(andforMedicareonly,thecollectionofurinebycatheter)Medicarepaysaflatrateof$3.00forHCPCScode36415anddoesnotcoverCPTcapillarybloodcollection(CPTcode36416).

24-hoururinespecimencollectionisreportedusingCPTcode81050(Volumemeasurementfortimedcollection,each)

Diagnosis(ICD-9)Codes

DiagnosisCodes,otherwiseknownasICD-9-CMCodes(InternationalClassificationofDisease,9thRevision,ClinicalModification),areusedtoidentifywhyatestorservicewasprovidedasopposedtoCPTcodeswhichidentifywhichspecifictestorservicewasprovided.

Medicareonlypaysforservicesthataremedicallynecessaryandindicated.DiagnosiscodesprovideameansforMedicarecarrierstodetermineifthetestssubmittedforpaymentmatchthepatientdiagnosis.DiagnosiscodesarerequiredoneveryPartBclaimsubmittedbyaphysicianincludingthoseforin-officelaboratorytests.

ICD-9CodingRules

1.Usecodesthatdescribesymptomsandsigns,asopposedtoadiagnosis,whenadiagnosishasnotbeenestablished.

2.Codetothegreatestspecificity.Usethree-digitcodesonlyifnotfurthersubdivided,4thor5thdigitsub-classificationsmustbeusediflisted.

3.Diagnosesdocumentedas:probable,suspected,questionable,rule-out,orworkingdiagnosisshouldnotbecodedasthoughtheyexist.Rather,codetothehighestdegreeofcertaintyforagivenencounterusingcodesforsigns,symptoms,abnormaltestresults,exposuretodisease,etc.

ICD-9CodingforUndiagnosedConditions

Whenapatientpresentswithanundiagnosedillness,theICD-9codeisdeterminedbythe"signsandsymptoms"present.Symptomsaredefinedaswhatthepatienttellsthephysician.Signsarewhatthephysicianobservesaspartofhisexaminationofthepatient.