Chapter 17: Pathology and Laboratory

Coding Tip About Pathology and Laboratory : When a pathology and laboratory procedure or service code description includes both the technical and the professional component and one of the components was not performed, report the appropriate code with modifier:

-26 to indicate that only the professional component was performed o indicate that only the technical component was performed. - TC to indicate that only the technical component was performed No modifier would be added of both the technical and professional components of the service were provided. service were provided.

The different methods for preparation, screening, and reporting a pap spear are:

Bethesda System,non ‐ Bethesda,non ‐ Bethesda ,automated screening

Shown on this slide is the :

Chemstrip Automated Urine Analyzer and a dipstick used for routine urinalysis.

Clinical and Laboratory Improvement Act (CLIA): To perform certain pathology and laboratory tests and submit claims to Medicare and Medicaid physician office labs must obtain certification under the:

Clinical Laboratory Improvement Act of 1988, called CLIA. A waiver is available for small office labs that perform only basic testing such as urine dip stick exams and fingerstick glucose testing. A special CLIA waiver number is assigned to these labs. The list of approved tests is updated periodically, which means that physician office labs must determine if they still qualify for a waiver.

In addition the following items may be included:

Complexity of symptoms • Final diagnosis • Pertinent physical findings • Diagnostic and therapeutic procedures • Concurrent problems • Follow‐ up care

Clinical pathology professional services include the following:

Directing and evaluating quality assurance and control procedures such a ensuring that test and procedures are properly performed ,recorded and validating test methodologies Supervising laboratory technicians Recommending follow‐up diagnostic tests, when appropriate.

Determinations when considering payment for claims:

Local Coverage Decisions, that affect only the area covered by the individual Medicare contractor, supplement the NCDs.

Pathology and Laboratory Section: The Pathology and Laboratory section is organized according to type of procedure performed. Pathology and laboratory procedures are listed alphabetically within each subsection, which include the following:

Organ or disease‐ oriented panels • Drug testing • Therapeutic drug assays • Evocative/ suppression testing • Consultations involving clinical pathology Consultations involving clinical pathology • Urinalysis • Chemistry • Hematology and coagulation • Immunology • Transfusion medicine • Microbiology • Microbiology • Anatomic pathology • Cytopathology • Cytogenetic studies • Surgical pathology • Transcutaneous procedures • Other procedures • Other procedures • Reproductive medicine procedures

Pathology and Laboratory Guidelines: Guidelines located at the beginning of the Pathology and Laboratory section provide instruction about the following:

Services in pathology and laboratory • Separate or multiple procedures • Subsection information • Unlisted services or procedures and • Special reports

Collection methods vary from those requiring no patient preparation to invasive procedures:

The reason for the test typically determines the appropriate collection method. Special collection methods, such as urethral catheterization, are indicated when a specimen cannot be obtained by more common techniques.

Certain laboratory procedures contain both a professional or physician component and a technical component.

The technical component of a laboratory procedure or service includes, but is not limited to, the cost of equipment, supplies, and technician salaries.

The tests listed below each panel identify the components of that panel:

To report an organ or disease‐oriented panel code all tests listed as included in the panel must be performed. No substitutions can be made.

. A dipstick is:

a small strip of plastic that is infused with a chemical that reacts to products in urine by changing color. It is considered preliminary and may be performed for screening purposes.

Pathologists often oversee the clinical laboratory and:

assume overall responsibility for test results.

When an unlisted procedure or service code is reported on a claim, a "special report" is: A service or procedure that is rarely performed, unusual, variable, or new may require a special report to be submitted so the third‐party payer can determine :

attached to the submitted claim to clarify the service or procedure performed. the medical appropriateness of the service or procedure. The special report should include a description of the nature, extent, and need for the procedure.

The CPT‐4 pathology and laboratory codes describe services performed on specimens that may include:

body fluids, tissue or cytological specimens to evaluate, prevent, diagnose, or treat a disease.

Specimen cells are typically obtained using :

brushing, washing, needle biopsy, or fine‐needle aspiration

Laboratory codes describe the performance of lab tests. These codes do not include:

collection of the specimen used to perform the test.

National Coverage Determinations (NCD): National Coverage Determinations or NCDs which define coverage for some services and procedures.

coverage for some services and procedures. Medicare administrative contractors apply the National Coverage Medicare administrative contractors apply the National Coverage.

Pap smears are reported with:

cytopathology codes.

Organ or disease‐oriented panels subsection codes are reported for a:

defined group of tests administered for a certain purpose. The panels were developed for coding purposes only and are not considered clinical parameters.

Cytopathology is the study of:

diseased cells.

When only one or several of the tests associated with a panel are performed:

do not report the panel code,Instead, report codes for each individual test performed.

Modifier ‐91 used to report a Repeat Clinical Diagnostic Laboratory Test,

is added to pathology and laboratory codes when procedures or services are repeated on the same date of service to obtain multiple results. 1

Modifier ‐51 used to report Multiple Procedures:

is not added to pathology and laboratory codes.

Modifier -90, Reference or Outside Laboratory:

is reported to indicate that an outside laboratory performed the service. (This modifier is often added to pathology and laboratory codes to indicate that the physician did not perform the actual test, but instead sent a specimen to an outside laboratory.)

Coding TIp: When reporting CLIA waived services to Medicare or Medicaid, HCPCS level II modifier ‐QW

must be appended to the pathology and laboratory codes.

Most urine tests are performed to diagnose or monitor:

renal or urinary tract disease.

When additional tests are performed in addition to those listed below the panel, separately code and :

report the additional tests in addition to the panel code.

The Bethesda System is a format for:

reporting cervical and vaginal cytology that includes a state of specimen adequacy, the general category such as if the specimen is within normal limits and a descriptive diagnosis .

Urine testing is easily performed and does not:

require an invasive skin puncture

As of 2002, CMS had issued more than 20 national coverage decisions regarding pathology and laboratory services, such as complete blood counts, which include lists of covered and non covered diagnoses. Pathology and laboratory NCDs were developed to:

simplify administrative requirements for clinical diagnostic services and promote national uniformity in processing Medicare claims.

A specimen is tissues:

submitted to the pathology department for evaluation.

The Pathology and Laboratory section of CPT includes:

subsections for organ or disease‐ oriented panels, drug testing, therapeutic drug assays, evocative and suppression testing, consultation, urinalysis, chemistry, hematology and coagulation, immunology, transfusion medicine, microbiology, anatomic pathology, cytopathology, cytogenetic studies, surgical pathology, transcutaneous procedures, reproductive medicine, and other procedures.

Surgical pathology codes are reported for:

the gross and microscopic examination of specimens submitted for pathological evaluation.

When reporting codes for professional and technical components of clinical laboratory services, standard practice is for:

the pathologist to report the professional component of clinical laboratory services.

Surgical pathology levels of service are determined by the:

type of exam and type of tissue

There are numerous methods for testing:

urine specimens.

Urine collection containers such as the one pictured here are:

used for routine urinalysis and are made of material that is clear. They contain lids that can be secured to prevent spills during transport.