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Chapter 33 : 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 the payors. It discusses laboratory responsibilities to ensure that correct and complete coding has been done and talks about the importance of the ICD-9-CM coding system and its relationship to proper billing. The chapter also discusses the fundamental principles of correct and complete coding. All aspects of effective financial management of the clinical laboratory begin with correct and complete coding for all services rendered. Professional services are identified by specific CPT-4 codes found in the anatomic pathology and cytology subsections, and by two specific codes in a clinical pathology consultation section. Modifiers are another important component of the CPT system, and are comprised of two-digit numbers which are attached to a specific code prior to the billing process. Since laboratory procedures are constantly evolving, particularly with the emergence of new technology, it is necessary for the CPT-4 system to undergo regular updates. The CPT system is obviously firmly entrenched in laboratory management as the primary tool for procedure coding and subsequent billing of laboratory services. Revenue codes comprise a system for categorizing and billing services which is recognized by Centers for Medicare and Medicaid Services (CMS) and most third-party payors. Requisitions may be manual (hard copy) or electronic but should be designed to facilitate the capture of all of the required data for accurate processing of an order as well as effective processing of a claim or invoice. Claims submitted to third-party payors can be electronic or manual in nature.

Citation: Baselski V, Weissfeld A, Sorrell F. 2004. Correct Coding of Billable Services in the Clinical Laboratory, p 557-566. In Garcia L, Baselski V, Burke M, Schwab D, Sewell D, Steele J, Weissfeld A, Wilkinson D, Winn W (ed), Clinical Laboratory Management. ASM Press, Washington, DC. doi: 10.1128/9781555817695.ch33

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References

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1.American Medical Association. 1999. Changing CPT: how it works. CPT Assist. 9:89.
2.American Medical Association. 2003. Current Procedural Terminology, CPT 2004, 4th ed. AMA Press, Chicago, Ill.
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.
4. Baselski, V.,, L. Garcia,, A. Weissfeld. 2001. The ABCs of CPT coding in microbiology. Clin.Microbiol. Newsl. 23:3742.
5. Brouch, K. 2003. AHIMA project offers insights into SNOWMED, ICD-9-CM mapping process. J. AHIMA 74:5255.
6. Burke, M.D. 2003. Clinical laboratory consultation: appropriateness to laboratory medicine. Clin. Chim. Acta 333:125129.
7. Kratz, A.,, and M. Laposata. 2002. Enhanced clinical consulting—moving toward the core competencies of laboratory professionals. Clin. Chim. Acta 319:117125.
8. Lorence, D. P.,, and I. A. Ibrahim. 2003. Benchmarking variation in coding accuracy across the United States. J. Health Care Finance 29:2942.
9. 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.
10. 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.
11. 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.
12. Travers, E. M. 1997. Clinical Laboratory Management, p. 759760. Williams and Wilkins, Baltimore, Md.

Tables

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Table 33.1

The CPT-4 system

Citation: Baselski V, Weissfeld A, Sorrell F. 2004. Correct Coding of Billable Services in the Clinical Laboratory, p 557-566. In Garcia L, Baselski V, Burke M, Schwab D, Sewell D, Steele J, Weissfeld A, Wilkinson D, Winn W (ed), Clinical Laboratory Management. ASM Press, Washington, DC. doi: 10.1128/9781555817695.ch33
Generic image for table
Table 33.2

Types of CPT-4 codes

FDA, Food and Drug Administration.

Citation: Baselski V, Weissfeld A, Sorrell F. 2004. Correct Coding of Billable Services in the Clinical Laboratory, p 557-566. In Garcia L, Baselski V, Burke M, Schwab D, Sewell D, Steele J, Weissfeld A, Wilkinson D, Winn W (ed), Clinical Laboratory Management. ASM Press, Washington, DC. doi: 10.1128/9781555817695.ch33
Generic image for table
Table 33.3

CPT-4 modifiers

Citation: Baselski V, Weissfeld A, Sorrell F. 2004. Correct Coding of Billable Services in the Clinical Laboratory, p 557-566. In Garcia L, Baselski V, Burke M, Schwab D, Sewell D, Steele J, Weissfeld A, Wilkinson D, Winn W (ed), Clinical Laboratory Management. ASM Press, Washington, DC. doi: 10.1128/9781555817695.ch33
Generic image for table
Table 33.4

Process and schedules for CPT code revisions

Citation: Baselski V, Weissfeld A, Sorrell F. 2004. Correct Coding of Billable Services in the Clinical Laboratory, p 557-566. In Garcia L, Baselski V, Burke M, Schwab D, Sewell D, Steele J, Weissfeld A, Wilkinson D, Winn W (ed), Clinical Laboratory Management. ASM Press, Washington, DC. doi: 10.1128/9781555817695.ch33

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