CMS NCCI Pathology Coding Guidelines - Effective October 1, 2009

The Centers for Medicare and Medicaid Services (CMS) developed the National Correct Coding Initiative (NCCI) to promote national correct coding methodologies and to control improper coding that leads to inappropriate payment of Part B claims. Periodically CMS updates the coding guidelines associated with the various specialties in the healthcare field.

Pathology/Laboratory coding guidelines have a few significant changes and new additions from the last version in 2008. It is very important that pathologists and laboratories adjust their coding processes to meet these guidelines. For a copy of the full CMS NCCI/MUE Pathology/Laboratory Coding Manual, use the following link and select Chapter 10 Pathology/Laboratory. Numerous other coding guidelines and general guidelines that have been in place for several years with CMS are provided in the document.

http://www.cms.hhs.gov/NationalCorrectCodInitEd/Downloads/NCCI_Policy_Manual.zip

1. Evocative/Suppression Testing

Evocative/suppression testing requires the administration of pharmaceutical agents to determine a patient's response to those agents. CPT® codes 80400-80440 describe the laboratory components of the testing. Administration of the pharmaceutical agent may be reported with CPT® codes 96365-96376. In the facility setting, these codes may be reported by the facility, but not the physician. In the non-facility setting, these codes may be reported by the physician. While supplies necessary to perform the testing are included in the testing CPT® codes, the appropriate HCPCS level II J code for the pharmacologic agent may be reported separately. Separate evaluation and management services including prolonged services (e.g., prolonged infusion) should not be reported separately unless a significant, separately identifiable service medically reasonable and necessary E&M is provided and documented.

2. CPT® codes 88384-88386 describe array-based evaluations of multiple molecular probes. If array-based evaluation of multiple molecular probes is performed by a laboratory scientist (i.e. PhD) or technician rather than a physician, it should not be reported with global CPT® code 88385 or 88386 since these codes include physician work. Rather, it should be reported as 88385-TC or 88386-TC which includes the non-physician work including interpretation.

3. Gross examination of a specimen is an integral component of pathology consultation during surgery (CPT® codes 88329-88334) and surgical pathology gross and microscopic examination (CPT® codes 88302-88309). CPT® code 88300 (level I –surgical pathology, gross examination only) should not be reported with any of the previously listed CPT® codes for examination of the same specimen.

4. CMS payment policy allows only one unit of service for CPT® codes 88321, 88323, and 88325 per beneficiary per provider on a single date of service. Providers should not report these codes on separate lines of a claim utilizing CPT® modifiers to bypass the MUEs for these codes.

5. The code descriptors for CPT® codes 83912 (molecular diagnostics; interpretation and report) and 88291 (cytogenetics and molecular cytogenetics, interpretation and report) do not define the units of service for these codes. The MUE value for each of these codes is “1.” CMS interprets these codes to include the synthesis with interpretation and report of all molecular diagnostic testing or cytogenetic/molecular cytogenetic testing respectively performed on a single date of service. These codes should not be reported with separate units of service based on the number of specimens or tests on a single date of service.

6. The MUE values for CPT® codes 86021 (antibody identification; leukocyte antibodies) and 86022 (antibody identification; platelet antibodies) are “1.” The code descriptors are plural, and CMS priced each of these codes to include all antibodies to leukocytes and platelets respectively in a single unit of service.

7. The unit of service for CPT® code 88172 (cytopathology, evaluation of fine needle aspirate; immediate cytohistologic study to determine adequacy of specimen(s)) is the separately identifiable lesion (tumor). Per the code descriptor all specimens from a single lesion are included in a single unit of service. If a physician performs multiple “passes” into the same lesion to obtain multiple specimens for immediate cytohistologic study, all specimens from the lesion are included in the single unit of service. If a physician evaluates fine needle aspirate specimens from more than one distinct, separate lesion, a separate unit of service may be reported for each lesion. The same concept applies to the unit of service for CPT® code 88173 (cytopathology, evaluation of fine needle aspirate; interpretation and report). A separate unit of service may be reported for each distinct, separate lesion, but only one unit of service may be reported for all specimens from a single lesion.

8. The unit of service for gross and microscopic surgical pathology (CPT® codes 88300-88309), pathology consultation during surgery (CPT® codes 88329, 88331, 88333), electron microscopy (CPT® codes 88348, 88349) and morphometric analysis (CPT® codes 88355-88358) is the specimen. A specimen is defined as tissue(s) that are submitted for individual and separate attention, examination, and diagnosis. It must be medically reasonable and necessary to submit the specimens for individual attention, examination, and diagnosis.

For example, if colonoscopy identifies two separate polyps at 15 cm and 25 cm, it may be medically reasonable and necessary to submit them as separate specimens. If one of the polyps is malignant, it may be important to know for future therapy which one was malignant.

9. The unit of service for special stains (CPT® codes 88312-88313) and immunohistochemistry (CPT® codes 88342, 88360, 88361) is each stain. If it is medically reasonable and necessary to perform the same stain on more than one specimen or more than one block of tissue from the same specimen, additional units of service may be reported for the additional specimen(s) or block(s). Physicians should not report more than one unit of service for a stain performed on a single tissue block.

a. For example, it is common practice to cut multiple levels from a tissue block and stain each level with the same stain. The multiple levels from the same block of tissue stained with the same stain should not be reported as additional units of service. Only one unit of service should be reported for the stain on multiple levels from the single tissue block. Additionally, controls performed with special stains should not be reported as separate units of service for the stain.

Rick Oliver, CHCO, CPC, MT(ASCP)

Pathology - Director of Compliance

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