With the 2022 National Correct Coding Initiative (NCCI) Policy Manual for Medicare Services now available, the Centers for Medicare & Medicaid Services (CMS) have included new guidelines related to laboratory services. Provided below are the most noteworthy additions to Chapter 10 for pathology and laboratory services (CPT codes 80000–89999). Note that “provider/supplier” or its plural forms were added to many sections of the chapter. To see smaller updates like these, please consult the NCCI manual. For clarity, each guideline is provided in its entirety with new words or sections in italic type. The identifying numbers are the same ones used by CMS in the NCCI Manual. Revisions took effect on January 1, 2022.
By contrast, some laboratory test results typically require separate follow-up testing which is implicit in the physician’s order. Such tests are termed reflex tests. For example, if an RBCantibody screen (CPT® code 86850) is positive, the laboratory proceeds to identify the RBC antibody. The reflex test is separately reportable. Similarly, if a urine culture is positive, the laboratory proceeds to organism identification testing which is separately reportable. In these examples, the initial results have limited clinical value without the separate follow-up test.
Other laboratory test results may or may not require additional testing in order to haveclinical value. This type of additional testing must be distinguished from reflex testing. The additional testing is not implicit in the initial physician order. An example is a test fora monoclonal protein band. The physician’s initial order does not implicitly include any additional testing. A laboratory shall not routinely perform additional testing to identify thetype of monoclonal protein unless ordered by the treating physician. If the patient has a knownmonoclonal gammopathy, the additional testing would not be appropriate unless ordered by thetreating physician.
If a laboratory procedure produces multiple reportable test results, only a single HCPCS/CPT code shall be reported for the procedure. If there is no HCPCS/CPT code that describes the procedure, the laboratory shall report a miscellaneous or unlisted procedure code with a single unit of service.
Proprietary Laboratory Analyses (PLA) codes are alpha-numeric codes describing manufacturers’ tests.
F. Molecular Pathology
3. Quantitation of extracted DNA and/or RNA is included in the payment for a molecular pathology procedure (e.g., CPT codes 81161–81408). Other HCPCS/CPT codes such as CPT code 84311 (Spectrophotometry…not elsewhere specified) shall not be reported for this quantitation.
6. All genomic sequencing procedures and molecular multianalyte assays (e.g., CPT codes 81410–81471), many multianalyte assays with algorithmic analyses (e.g., CPT codes 81490–81599, 0004M-XXXXM), and many Proprietary Laboratory Analyses (PLA) (e.g., CPT codes 0001U-XXXXU) are DNA or RNA analytic methods that simultaneously assay multiple
4. CPT code 83704 (Lipoprotein, blood; quantitation of lipoprotein particle number(s) (e.g., by nuclear magnetic resonance spectroscopy) (includes lipoprotein particle subclass(es), when performed) is generally not reportedon the same date of service as CPT codes80061 (Lipid panel…), 82465 (Cholesterol…total), 84478 (triglycerides), and 83718 (Lipoprotein, direct measurement; high density cholesterol (HDL cholesterol)). Typically, a lipid panel is performed, and if necessary, the physician may order an NMR lipoprotein panel as a follow-up study to further characterize the abnormality. However, uncommonlya patient might have a previously diagnosed lipid panel abnormality and separate NMR lipoprotein panel abnormality that require retesting after a therapeutic intervention.
H. Hematology and Coagulation
1. If a treating physician orders an automated complete blood count with automated differential WBC count (CPT code 85025) or without automated differential WBC count (CPT code 85027), the laboratory sometimes examines a blood smear in order to complete the ordered test based on laboratory selected criteria flagging the results for additional verification. The laboratory shall not report CPT code 85007(Blood count; blood smear, microscopic examination with manual WBC differential count) or CPT code 85008 (Blood count; blood smear, microscopic examination without manual WBC differential count) for the examination of a blood smear to complete the ordered automated complete blood count (CPT codes 85025 or 85027). The same principle applies if the treating physician orders any type of blood count and the laboratory’s practice is to perform an automated complete blood count with or without automated differential WBC count.
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