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Chapter 35 : Correct Coding of Billable Services in the Clinical Laboratory

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Abstract:

This chapter explains the importance of using the standardized coding systems recognized by payors. It lists a set of critical parameters that one must specify in accounting for laboratory services. For each parameter, the laboratory must use standard language to communicate with payors and for use in benchmarking comparisons of practices to assess efficiency and effectiveness of services provided. The purpose of current procedural terminology (CPT) is to provide a uniform language that accurately describes medical, surgical, and diagnostic services for financial and administrative purposes and to serve as a standard means of identifying and documenting services performed. There is an established hierarchy for choice of CPT codes that places analyte first, followed by method, and then finally the use of a generic “not otherwise specified” code. Under capitated or prospective payment systems, laboratories may find themselves in the situation of representing financial liabilities rather than revenue generators. To balance this perception, it is extremely important for laboratories to develop mechanisms to document all work performed in a given clinical setting. The chapter discusses inpatient diagnosis coding, outpatient diagnosis coding, besides other patient groups. In most large laboratories, there are multiple departments performing testing, and it is necessary to assign each entity designated as an independent financial center a unique identifier for financial analysis purposes. It is recommended that the laboratory performs annual updates of procedure coding, including impact of changes on service manuals, requisitions and order entry systems, and charge masters.

Citation: Baselski V, Weissfeld A, Sorrell F. 2014. Correct Coding of Billable Services in the Clinical Laboratory, p 625-636. In Garcia L (ed), Clinical Laboratory Management, Second Edition. ASM Press, Washington, DC. doi: 10.1128/9781555817282.ch35
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References

/content/book/10.1128/9781555817282.chap35
1.American Medical Association. 2012. Principles of CPT Coding. AMA Press, Chicago, IL.
2.American Medical Association. 2013. Current Procedural Terminology, Professional Edition. AMA Press, Chicago, IL.
3. Averill, R. F.,, R. L. Mullin,, B. A. Steinbeck,, N. I. Goldfield,, and T. M. Grant. 2001. Development of the ICD-10 procedure coding system (ICD-10-PCS). Top. Health Inf. Manag. 21:5488. [PubMed]
4. Baselski, V.,, L. Garcia,, and A. Weissfeld. 2001. The ABCs of CPT coding in microbiology. Clin. Microbiol. Newsl. 23:3742.
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8. Forsman, R. W. 1996. Why is the laboratory an afterthought for managed care organizations? Clin. Chem. 42:813816. [PubMed]
9. Grider, D. 2012. Principles of ICD-10-CM Coding. AMA Press, Chicago, IL.
10.IOM. 2000. Medicare Laboratory Payment Policy Now and in the Future. National Academy Press, Washington, DC.
11. Kovar, M.,, and E. Shannon. 2011. Laboratory pricing: charge master risks and rewards. New Perspect. 30:1517.
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13.The Lewin Group. 2008. Laboratory medicine. A national status report. https://www.futurelabmedicine.org/pdfs/2007%20status%20report%20laboratory_medicine_-_a_national_status_report_from_the_lewin_group.pdf, accessed October 15, 2012.
14. Lorence, D. P.,, and I. A. Ibrahim. 2003. Benchmarking variation in coding accuracy across the United States. J. Health Care Finance 29:2942. [PubMed]
15. MacMillan, D. H.,, B. L. Soderberg,, and M. Laposata. 2001. Regulations regarding reflexive testing and narrative interpretations in laboratory medicine. Am. J. Clin. Pathol. 116(Suppl.):S129S132. [PubMed]
16. Malone, B. 2012. The future of lab utilization management. Are lab formularies the answer? Clin. Lab. News 38:1, 67.
17. McDonald, C. J.,, S. M. Huff,, J. G. Suico,, G. Hill,, D. Leavelle,, R. Aller,, A. Forrey,, K. Mercer,, G. DeMoor,, J. Hook,, W. Williams,, J. Case,, and P. Maloney. 2003. LOINC, a universal standard for identifying laboratory observations: a year update. Clin. Chem. 49:624633. [PubMed]
18. Schubart, J. R.,, C. E. Fowler,, G. R. Donowitz,, and A. F. Connors, Jr. 2001. Algorithm-based decision rules to safely reduce laboratory test ordering. IFIP World Conf. Ser. Med. Inf. 10:523527.
19. Travers, E. M. 1997. Clinical Laboratory Management, p. 759760. Williams and Wilkins, Baltimore, MD.

Tables

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Table 35.1

The CPT system

Citation: Baselski V, Weissfeld A, Sorrell F. 2014. Correct Coding of Billable Services in the Clinical Laboratory, p 625-636. In Garcia L (ed), Clinical Laboratory Management, Second Edition. ASM Press, Washington, DC. doi: 10.1128/9781555817282.ch35
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Table 35.2

Types of CPT-4 codes

Citation: Baselski V, Weissfeld A, Sorrell F. 2014. Correct Coding of Billable Services in the Clinical Laboratory, p 625-636. In Garcia L (ed), Clinical Laboratory Management, Second Edition. ASM Press, Washington, DC. doi: 10.1128/9781555817282.ch35
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Table 35.3

CPT modifiers used in laboratory medicine

Citation: Baselski V, Weissfeld A, Sorrell F. 2014. Correct Coding of Billable Services in the Clinical Laboratory, p 625-636. In Garcia L (ed), Clinical Laboratory Management, Second Edition. ASM Press, Washington, DC. doi: 10.1128/9781555817282.ch35
Generic image for table
Table 35.4

Process and schedules for CPT code revisions

Citation: Baselski V, Weissfeld A, Sorrell F. 2014. Correct Coding of Billable Services in the Clinical Laboratory, p 625-636. In Garcia L (ed), Clinical Laboratory Management, Second Edition. ASM Press, Washington, DC. doi: 10.1128/9781555817282.ch35

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