The maximum amount Medicare will pay for specific CPT codes are set in what is called the Clinical Laboratory Fee Schedule. Each year in January this schedule is updated to reflect consumer pricing index, cost of living, inflation, etc. Proper reimbursement requires proper coding. The American Medical Association publishes the CPT codebook in various versions depending on the user’s specific needs. The following are CPT changes and updates for 2011 in regards to the Clinical Laboratory Fee Schedule. For further research you can access the Centers for Medicare and Medicaid Services (CMS) or the American Medical Association (AMA).
Clinical Laboratory Fee Schedule 2011 Updates
Released: May 28, 2010
Collecting Reimbursement in Clinical Laboratory Practice.
Reimbursement for provided services performed by providers (laboratory) is made by commercial payers such as Aetna or United Healthcare or federal intermediaries such as Medicare or Medicaid. Reimbursement is based on claims and documentation filed by providers using medical diagnosis and procedure codes or CTPT codes.
CPT stands for Current Procedural Terminology. CPT codes describe medical procedures, services and supplies. CPT codes are used by physicians, hospitals, laboratories and other health care professionals to report medical and diagnostic provided services and procedures for payment purposes. The CPT coding system is maintained by the American Medical Association (AMA). The CPT codes are revised and updated annually by the AMA. CPT codes are mandated by Medicare, Medicaid and are also required by all other third party payers.
All CPT codes are five digit code followed by the definition. The CPT coding system is divided into eight sections and Pathology and Laboratory is the fifth section and its CPT codes are from 80048-89356 digit numbers. The Pathology and Laboratory section of CPT codes is then divided into 18 subsections. For example Immunology subsection is from 86000-86849. Codes 83890-83914 are intended for use with molecular diagnostic techniques and these codes are coded by procedure rather then analyte like those for immunology or chemistry. In addition, when molecular diagnostic procedures are performed to test for oncology, hematology, or genetics appropriate modifier to specify condition tested should be used. For example testing for cystic fibrosis (CF) mutation analysis by molecular procedure, which screens for many mutations on the CF gene, molecular CPT codes used are follow with the 8A modifier that specifies CF. For example 83891-8A, indicates that 83891 is the procedure, which incase is the isolation or extraction of highly purified nucleic acid, and the modifier is 8A, which indicates cystic fibrosis condition.
It is important that the medical coder or the biller is familiar with different types of insurance plans, regulations and, of course, CPT and The International Classification of Diseases or ICD-9 codes and guidelines. This enables the coder to assign correct codes and service levels for the procedures or services performed and supplies used to diagnose or treat the patient.
A provider or coder must first choose the name and the associated code of the procedure or service provided. If necessary, modifiers (as described above) are chosen and added to the selected services and procedural codes. All used codes for services or procedures provided must be also documented in the patient medical record.
New Test Codes:
- 801XX Drug screen, qualitative; multiple drug classes other than chromatographic method, each procedure (THIS CPT CODE TAKES THE PLACE OF G0430)
- 829XX Gastric acid analysis, includes pH if performed, each specimen
- 838XX Microfluidic analysis utilizing an integrated collection and analysis device, tear osmolarity
- 841XX Placental alpha microglobulin-1 (PAMG-1), cervicovaginal secretion, qualitative Hematology and Coagulation
- 855XX Phospholipid neutralization; hexagonal phospholipid Immunology
- 864XX Tuberculosis test, cell mediated immunity antigen response measurement; enumeration of gamma interferon-producing T-cells in cell suspension Transfusion Medicine
- 869XX Blood typing; antigen testing of donor blood using reagent serum, each antigen test Microbiology
- 875XX1 Infectious agent detection by nucleic acid (DNA or RNA); influenza virus, reverse transcription and amplified probe technique, each type or subtype
- 875XX2 Infectious agent detection by nucleic acid (DNA or RNA); influenza virus, multiplex for multiple types or sub-types, reverse transcription and amplified probe technique, first 2 types or sub-types
- 875XX3 Infectious agent detection by nucleic acid (DNA or RNA); influenza virus, for multiple types or sub-types, multiplex reverse transcription and amplified probe technique, each additional influenza virus type or sub-type beyond 2 (List separately in addition to code for primary procedure)
- 879XX Infectious agent drug susceptibility phenotype prediction using regularly updated genotypic bioinformatics; HIV-1, other region (eg, integrase, fusion)
NOTE: The following temporary G codes were established internally by CMS for pricing on the CLFS
- G9143 Pharmacogenomic testing for Warfarin response
- G0432 Infectious agent antibody detection by enzyme immunoassay (EIA) technique, HIV-1 and/or HIV-2, screening SHORT DESCRIPTOR: EIA HIV-1/HIV-2 screen
- G0433 Infectious agent antibody detection by enzyme-linked immunosorbent assay (ELISA) technique, HIV-1 and/or HIV-2, screening SHORT DESCRIPTOR: ELISA HIV-1/HIV-2 screen
- G0435 Infectious agent antibody detection by rapid antibody test, HIV-1 and/or HIV-2, screening SHORT DESCRIPTOR: Oral HIV-1/HIV-2 screen
NOTE: Concerning the three HIV test codes (G0432, G0433, and G0435) please note that the descriptors for these three test codes could change. Any changes will be updated accordingly.
- 84145 Procalcitonin (PCT)
- 84431 Thromboxane metabolite(s), including thromboxane if performed, urine
- 86352 Cellular function assay involving stimulation (e.g., mitogen or antigen) and detection of biomarker (e.g., ATP)
- G0430 Drug screen, qualitative; multiple drug classes other than chromatographic method, each procedure
- G0431 Drug screen, qualitative; single drug class method (e.g., immunoassay, enzyme assay), each drug class
This listing includes the most recent codes provided by the American Medical Association (AMA), and that it is subject to change. The updates provided here are referenced and reproduced from the CMS website located at http://www.cms.gov/ClinicalLabFeeSched/Downloads/CY2011-Public-Meeting-New-Test-Codes.pdf.
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