Sample page. Laboratory Services. Coding and Payment Guide

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1 Coding and Payment Guide 218 Laboratory Services An essential coding, billing and reimbursement resource for laboratory and pathology services POWER UP YOUR CODING with Optum36, your trusted coding partner for 32 years. Visit optum36coding.com.

2 Contents Getting Started with Coding and Payment Guide...1 Resequencing of CPT Codes...1 ICD-1-CM...1 Detailed Code Information...1 Appendix Codes and Descriptions...1 CCI Edit Updates...1 Index...1 General Guidelines...1 Sample Page and Key...1 Claim Forms...4 Glossary and Appendixes...4 Documentation Requirements...4 Reimbursement for Laboratory and Pathology Services...5 ESRD Consolidated Billing...6 Procedure Codes...7 The Structure of the CPT Book...7 Category I Codes...7 Category II Codes...7 Category III Codes...7 CPT Coding Conventions...7 Unlisted Procedures...7 Modifiers...7 Venous and Arterial...9 Organ or Disease Oriented Panels...16 Presumptive Drug Class Screening...28 Definitive Drug Testing...29 Therapeutic Drug Assays...79 Evocative/Suppression Testing Urinalysis Molecular Pathology Geno Seq and Other Molec Multianalyte Assay Multianalyte Assays with Algorithmic Analyses Chemistry Hematology and Coagulation Immunology Tissue Typing Transfusion Medicine Microbiology Anatomic Pathology Cytopathology Cytogenetic Studies Surgical Pathology In Vivo Laboratory Procedures Other Procedures Reproductive Medicine Appendix Correct Coding Initiative Update CPT Index...73 HCPCS Level II Definitions and Guidelines Medicare Official Regulatory Information Glossary Appendix 1. CLIA Waived Tests Contents i

3 Getting Started with Coding and Payment Guide The is designed to be a guide to the specialty procedures classified in the CPT books. It is structured to help coders understand procedures and translate physician narrative into correct CPT codes by combining many clinical resources into one, easy-to-use source book. The book also allows coders to validate the intended code selection by providing an easy-to-understand explanation of the procedure and associated conditions or indications for performing the various procedures. As a result, data quality and reimbursement will be improved by providing code-specific clinical information and helpful tips regarding the coding of procedures. For ease of use, Coding and Payment Guide for Laboratory Services lists the CPT and HCPCS level II codes in ascending numeric order. Included in the code set are all surgery and medicine codes pertinent to the specialty. Each CPT code is followed by its official code description. Resequencing of CPT Codes The American Medical Association (AMA) employs a resequenced numbering methodology. According to the AMA, there are instances where a new code is needed within an existing grouping of codes, but an unused code number is not available to keep the range sequential. In the instance where the existing codes were not changed nor had only minimal changes, the AMA has assigned a code out of numeric sequence with the other related codes being grouped together. The resequenced codes and their descriptions have been placed with their related codes, out of numeric sequence. Codes within the Optum36 Coding and Payment Guide series display in their resequenced order. Resequenced codes are enclosed in brackets for easy identification. ICD-1-CM Overall, the 1th revision goes into greater clinical detail than did ICD-9-CM and addresses information about previously classified diseases, as well as those diseases discovered since the last revision. Conditions are grouped with general epidemiological purposes and the evaluation of health care in mind. New features have been added, and conditions have been reorganized, although the format and conventions of the classification remain unchanged for the most part. Detailed Code Information One or more columns are dedicated to each procedure or service to a series of similar procedures/services. Following the specific HCPCS Level II and CPT code and its narrative, is a combination of features. A sample is shown on page 2. The black boxes with numbers in them correspond to the information on the page following the example. Appendix Codes and Descriptions Some procedure codes are presented in a less comprehensive format in the appendix. The CDT and CPT codes appropriate to the specialty are included the appendix with the official code description. The codes are presented in numeric order, and each code is followed by an easy-to-understand lay description of the procedure. CCI Edit Updates The Coding and Payment Guide series includes the a list of codes from the official Centers for Medicare and Medicaid Services National Correct Coding Policy Manual for Part B Medicare Contractors that are considered to be an integral part of the comprehensive code or mutually exclusive of it and should not be reported separately. The codes in the Correct Coding Initiative (CCI) section are from version 23.3, the most current version available at press time. The CCI edits are now located in a section at the back of the book. Optum36 maintains a website to accompany the Coding and Payment Guide series and posts updated CCI edits on this website so that current information is available before the next edition. The website address is The 218 edition password is: SPEC18DLC. Please note that you should log in each quarter to ensure you receive the most current updates. An reminder will also be sent to you to let you know when the updates are available. Index A comprehensive index is provided for easy access to the codes. The index entries have several axes. A code can be looked up by its procedural name or by the diagnoses commonly associated with it. Codes are also indexed anatomically. For example: Skin Tests Candida, Coccidioidomycosis, 8649 Histoplasmosis, 8651 Other Antigen, Tuberculosis, 8658 General Guidelines Providers The AMA advises coders that while a particular service or procedure may be assigned to a specific section, the service or procedure itself is not limited to use only by that specialty group. Additionally, the procedures and services listed throughout the book are for use by any qualified physician or other qualified health care professional or entity (e.g., hospitals, laboratories, or home health agencies). Keep in mind that there may be other policies or guidance that can affect who may report a specific service. Supplies Some payers may allow physicians to separately report drugs and other supplies when reporting the place of service as office or other nonfacility setting. Drugs and supplies are to be reported by the facility only when performed in a facility setting. Professional and Technical Component Some pathology codes have a technical and a professional component. When physicians do not own their own equipment and send their patients to outside testing facilities, they should append modifier 26 to the procedural code to indicate they performed only the professional component. Sample Page and Key On the following pages are a sample page from the book displaying the format of Coding and Payment Guide with each element identified and explained on the opposite page. Getting Started with Coding and Payment Guide 1

4 Infectious agent detection by nucleic acid (DNA or RNA); Chlamydia trachomatis, direct probe technique Chlamydia trachomatis, amplified probe technique Chlamydia trachomatis, quantification Explanation C. trachomatis is a frequently occurring sexually transmitted disease. It may cause nonspecific urethritis or pelvic inflammatory disease (PID), frequently asymptomatic in women. Another serotype also causes conjunctivitis. Code 8749 requires that the specimen is treated to isolate the DNA using direct probe and may be requested as Chlamydia trachomatis or C. trachomatis by direct DNA probe. In code the DNA is amplified using a technique such as polymerase chain reaction (PCR). It may be requested as Chlamydia trachomatis or C. trachomatis by polymerase chain reaction. Code reports quantification only. This test may be requested as Chlamydia trachomatis or C. trachomatis DNA quantification. Coding Tips Molecular pathology procedures ( ) should not be reported in combination with or instead of the infection agent detection by nucleic acid procedures ( ). To report Chlamydia pneumoniae infectious agent detection by nucleic acid, consult CPT codes Reimbursement Tips Infectious agent molecular diagnostic testing using nucleic acid probes is reported with CPT codes , These CPT codes include all the molecular diagnostic processes. CPT codes should not be additionally reported with these CPT codes. Terms To Know chlamydia trachomatis. Bacterium that causes a common venereal disease. Symptoms of chlamydia are usually mild or absent, however, serious complications may cause irreversible damage, including cystitis, pelvic inflammatory disease, and infertility in women and discharge from the penis, prostatitis, and infertility in men. Genital chlamydial infection can cause arthritis, skin lesions, and inflammation of the eye and urethra Synonym(s): Reiter's syndrome. DNA. Deoxyribonucleic acid. RNA. Ribonucleic acid. ICD-1-CM Diagnostic Codes A55 Chlamydial lymphogranuloma (venereum) A56. Chlamydial infection of lower genitourinary tract, unspecified A56.1 Chlamydial cystitis and urethritis A56.2 Chlamydial vulvovaginitis A56.9 Other chlamydial infection of lower genitourinary tract A56.11 Chlamydial female pelvic inflammatory disease A56.19 Other chlamydial genitourinary infection A56.2 Chlamydial infection of genitourinary tract, unspecified A56.3 Chlamydial infection of anus and rectum A56.4 Chlamydial infection of pharynx A56.8 Sexually transmitted chlamydial infection of other sites A63.8 Other specified predominantly sexually transmitted diseases A64 Unspecified sexually transmitted disease A71. Initial stage of trachoma A71.1 A71.9 A74. A74.81 A74.89 A74.9 J16. N34.1 Z11.3 Z11.8 Medicare Edits Active stage of trachoma Trachoma, unspecified Chlamydial conjunctivitis Chlamydial peritonitis Other chlamydial diseases Chlamydial infection, unspecified Chlamydial pneumonia Nonspecific urethritis Encounter for screening for infections with a predominantly sexual mode of transmission Encounter for screening for other infectious and parasitic diseases Nat l Limit * with documentation Mid-Point Modifiers Floor Status MUE 1(3) 2(3) 1(3) Medicare References None Microbiology Microbiology 545

5 Correct Coding Initiative Update 23.3 vindicates Mutually Exclusive Edit , v, v 3645 v, 3646 v, 3651 v,, 96523, v , v,, J T, 216T, 228T, 23T, , , , , 36, , , 3644, v, , 366, 3664, 43752, , T, 216T, 228T, 23T, , , , , 36, , , v, v, , 366, 3664, 43752, , T, 216T, 228T, 23T, , , , , 36, , , 3644, v, , 366, 3664, 43752, , T, 216T, 228T, 23T, 342T v, , , , , 36, , , 3644, v, , 366, 3664, 43752, ,, J T, 216T, 228T, 23T, , , , , 36, , , 3644, v, , 366, 3664, 43752, , , , , , 64461, 64463, 64479, 64483, , 64493, , 6999, , , , 93318, 93355, 942, 942, 9425, , 9477, , 95819, 95822, 95829, 95955, , 96372, , , 9915, , , , , , , , , , , , 99466, , 99485, , G38-G384, G463,, J T, 216T, 228T, 23T, , , , , 36, , , 3644, , 366, 3664, 43752, , , , , , 64461, 64463, 64479, 64483, , 64493, , 6999, , , , 93318, 93355, 942, 942, 9425, , 9477, , 95819, 95822, 95829, 95955, , 96372, , , 9915, , , , , , , , , , , , 99466, , 99485, , G38-G384, G463,, J , , , , , , 35286, , , , 35286, 365, , 6999, J , , , 36625, 6999, , , 935, J67, J21 848, 851, 8233, 82374, 82435, 82565, 82947, 84132, 84295, , 8231, 82374, 82435, 82565, 82947, 84132, 84295, 8452 No CCI edits apply to this code , 82435, 84132, , 851, 869, 876, 824, 82247, 8231, 82374, 82435, 82565, 82947, 8475, 84132, 84155, 84295, 8445, 8446, 8452 No CCI edits apply to this code , 82465, 83718, 83721, , 851, 876, 824, 8231, 82374, 82435, 82565, 82947, 841, 84132, 84295, 8452 CCI Edits CCI Edits Update