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Chapter and verse on next year’s CPT code changes
December 2004
Lisa Miller
Many of the CPT 2005 changes in the pathology and laboratory section either
replace or expand on existing services. Changes affecting clinical laboratory
services are in the chemistry, hematology and coagulation, immunology, and microbiology
subsections. The most significant of the changes are the additions and revisions
to the morphometric analysis and in situ hybridization codes in the surgical
pathology subsection, the series of new procedures to report flow cytometry
testing and interpretation, a new appendix for genetic testing, and guidelines
to molecular diagnostic and cytogenetic subsections to clarify appropriate reporting
of genetic tests.
Chemistry
New code 82045 Albumin; ischemia modified was added to the series of albumin codes to describe the different methods of albumin testing for cardiovascular events preceded by ischemia. This code should be used to codify a novel analysis that may aid in the triage of patients evaluated for acute coronary syndromes. This test is also known as cobalt albumin binding, based on the fact that the ability of albumin to bind cobalt is decreased in the setting of myocardial ischemia.
New code 82656 Elastase, pancreatic (EL-1), fecal, qualitative or semiquantitative describes a stool test for determining exocrine pancreatic function. The test uses an enzyme-linked immunosorbent assay (ELISA), and formerly would have been reported with the method-specific code 83516, since there were no analyte-specific codes to specifically report the fecal pancreatic elastase-1 analyte, nor were there codes to codify the specimen preparation that is required before the actual analysis can take place.
Existing codes 83013 Helicobacter pylori; breath test analysis for urease activity, non-radioactive isotope (eg, C-13) and 83014 Helicobacter pylori; drug administration were revised editorially to distinguish testing methods for H. pylori. The code descriptors now clarify that these services are intended for reporting breath test analysis for urease activity. New code 83009 Helicobacter pylori, blood test analysis for urease activity, non-radioactive isotope (eg, C-13) was developed to describe blood test analysis for urease activity. Following the code is a new instructional note to clarify that codes 83013 and 83014 should be used for breath test analysis. To provide better clarity in coding H. pylori services, the radiology and medicine sections of CPT were also updated to include instructional cross-references to assist users with proper code selection.
Code 83630 was established to report qualitative determination of lactoferrin in feces. Before the addition, similar to pancreatic elastase, there was no analyte-specific code in CPT to identify fecal lactoferrin or the stool preparatory steps in this analysis. This code describes a test to detect intestinal inflammation, differentiate inflammatory from noninflammatory gastrointestinal disease, monitor patient response to therapy, and predict inflammatory bowel disease recurrence.
Code 84163 describes a screening test for pregnancy-associated plasma protein-A (PAPP-A), which can aid in identifying women at highest risk of carrying a fetus with trisomy 21, trisomy 18, or other chromosomal abnormalities.
Existing code 84165 originally was used to codify all protein electrophoresis specimen types. Acknowledging that non-serum specimens require an additional concentration step, CPT 2005 has divided this procedure into two codes: 84165 Protein; electrophoretic fractionation and quantitation, serum and 84166 Protein; electrophoretic fractionation and quantitation, other fluids with concentration (eg, urine, CSF) . The revised and new codes have a professional component RVU that will pay for the professional interpretation of this analysis, and will be acknowledged by Medicare.
Hematology and coagulation
Editorial changes were made to code 85046 Blood count; reticulocytes, automated, including one or more cellular parameters (eg, reticulocyte hemoglobin content (Chr), immature reticulocyte fraction (IRF), reticulocyte volume (MRV), RNA content), direct measurement to describe multiple different but clinically similar automated reticulocyte parameters and to clarify that this code describes a direct measurement.
Immunology
Three new CPT codes for lymphocyte subsets have been added to the immunology
subsection to include additional markers commonly performed in immunocompetency
and transplant assessment. These codes were developed solely for quantitative
analysis, as numerical monitoring of these conditions does not usually require
a pathologist to interpret the results. Code 86064 was created to report total
count of B cells; 86379 was created to report Natural Killer (NK) cells, total
count; and 86587 describes total count of stem cells (that is, CD34 positive
cells).
Similar to the modification of the protein electrophoresis code (84165), immunofixation electrophoresis also has two codes to acknowledge the additional concentration step. Code 86334 has been revised to specify immunofixation electrophoresis analysis of serum, and 86335 was created to identify analysis of other fluids with concentration. Both codes also have a Medicare-covered professional component for the pathologist’s interpretation.
Microbiology
In CPT 2004, code 87046 Culture, bacterial; stool, aerobic, additional pathogens, isolation and presumptive identification of isolates, each plate was revised to clarify that the bacterial culture was aerobic. The revision inadvertently eliminated the words "each plate." In CPT 2005, an editorial change was made to restore the descriptor language. Additionally, the cross-reference for Giardia antigen was revised to direct users to the correct code.
New code 87807 has been added to the list of direct optical observation immunoassay codes for microbiology (87802-87899). This will now allow labs to report respiratory syncytial viral antigen by immunoassay with direct optical observation. Before CPT 2005, respiratory syncytial virus antigen was reportable only with a method-specific code or for immunofluorescent or enzyme immunoassay techniques.
Cytopathology
Another important change to CPT 2005 is the addition of new flow cytometry testing and interpretation codes. A series of five codes were developed that now allow the different services previously included in deleted code 88180 to be reported. Because the number of clinical flow cytometric applications has grown significantly in the past few years, as have the number of antibodies used to evaluate hematologic conditions, increased use has caused some payers to scrutinize reimbursement for these services. The new codes were developed to address the concerns about overuse and perceived overpayment of flow cytometry services.
Code 88184 Flow cytometry, cell surface, cytoplasmic, or nuclear marker, technical component only; first marker and add-on code 88185 Flow cytometry, cell surface, cytoplasmic, or nuclear marker, technical component only; each additional marker were established to report the technical component of flow cytometry procedures. Since the new codes distinguish the initial marker from additional markers, a cross-reference was added following code 88185 to instruct users to report code 88185 in conjunction with code 88184. To report interpretation of panel markers, use code 88187 for two to eight markers, 88188 for nine to 15 markers, and 88189 for 16 or more markers. These codes were developed solely for interpretation, and only one unit of service should be reported for professional interpretation per specimen. For example, if a 15-marker panel is being performed on a lymph node sample by flow cytometry and is interpreted by the pathologists, the appropriate coding would be one unit of 88184, 14 units of 88185, and one unit of 88188.
Additional cross-references were added in the immunology subsection following codes 86064, 86379, and 86587 to direct the user to 88182 and 88184-88189 for flow cytometric immunophenotyping for the assessment of potential hematolymphoid neoplasia. Modifiers "26" and "TC" cannot be used with these codes, as they have been assigned status code "O" on the 2005 fee schedule for physician services.
Surgical pathology
Additionally, significant changes were made to immunohistochemistry and in situ hybridization services that will affect how CPT codes should be applied.
CPT 2005 now separates manual morphometric analysis from computer-assisted
technology with the revision of 88360 Morphometric analysis, tumor immunohistochemistry
(eg, Her-2/neu, estrogen receptor/progesterone receptor), quantitative or semiquantitative,
each antibody; manual and addition of code 88361 Morphometric analysis,
tumor immunohistochemistry (eg, Her-2/neu, estrogen receptor/progesterone receptor),
quantitative or semiquantitative, each antibody; using computer-assisted technology.
A new instructional note was added after 88361 to direct users to report
88367 and 88368 for morphometric analysis performed in conjunction with in situ
hybridization. The existing parenthetical note following 88361 was revised to
reflect the addition of code 88360. These codes should not be reported with
88342 Immunohistochemistry (including tissue immunoperoxidase), each
antibody unless each procedure is for a different antibody. Immunohistochemistry
reported with qualitative grading, such as 1+ to 3+, should be reported as 88342.
Code 88365 In situ hybridization (eg, FISH), each probe was also revised to remove the word "tissue" to clarify that this code can also be used to report in situ hybridization of cytologic preparations. Use of quantitative in situ hybridization assays has increased, and this has led to the addition of two new codes to report morphologic evaluation of quantitative or semiquantitative in situ hybridization methods. Codes 88367 Morphometric analysis, in situ hybridization (quantitative or semi-quantitative) each probe; using computer-assisted technology and 88368 Morphometric analysis, in situ hybridization (quantitative or semi-quantitative) each probe; manual were established to differentiate manual and computer-assisted techniques. Qualitative in situ hybridization preparations should be coded as 88365. A new cross-reference was added following code 88365 to instruct users not to report 88365 in conjunction with codes 88367 or 88368 for the same probe, as the cost is included in the latter two codes. The unit of service on all three of these codes has been clarified to be "per probe."
The in situ hybridization codes within the anatomic pathology section (88365-88368) are intended to be used when performed as an ancillary analysis to surgical pathology and cytopathology services. When in situ hybridization is done as an ancillary analysis to cytogenetic studies, codes in the cytogenetic range (88271-88275) should be assigned.
Reproductive medicine procedures
CPT 2004 established code 89346 to report storage of human oocytes. In CPT
2005, an editorial change was made to replace the word "oocyte" with "oocyte(s)."
This is a nonphysician service and should be reported separately in addition
to physician services.
Genetic testing code modifiers
Of exceptional significance in CPT 2005 is the addition of appendix I, which is a list of modifiers for molecular genetics testing. While these modifiers are not intended to alter payment for molecular laboratory procedures related to genetic testing, the modifiers enable providers to submit more complete and specific information for claims adjudication, as they provide more information on the purpose for molecular laboratory procedures without altering test descriptors. The modifier system is classified by gene mutation. The first (numeric) digit indicates the disease category, and the second (alpha) digit denotes gene type. Each category ends with a "not otherwise specified" code for generic use. The modifiers are intended for use with molecular diagnostic codes (83890-83912) and cytogenetic studies (88230-88299), as well as HCPCS codes. They should not be applied when using an individual procedure to test for multiple genes. In addition to the inclusion of appendix I, which is found in the appendices section of the CPT manual, general guidelines have been added to the molecular diagnostic and cytogenetic subsections to direct users to see appendix I for the list of appropriate modifiers to report with these procedures.
New CPT codes will be effective Jan. 1, 2005. Although Medicare recognizes these changes as of this date, other payers may delay entering the new codes into their computer systems. Providers should check with their commercial payers about the effective date for the new codes.
ICD-9-CM
ICD-9-CM 2005 contains several changes for cervical cytology to differentiate between diagnoses based on Pap test results and those based on biopsy results. New entries under category 795.0 Abnormal Papanicolaou smear of cervix and cervical HPV were expanded to reflect more accurately the terminology used in the revised Bethesda system for ASC-US, AGUS, dysplasia, unsatisfactory, and nonspecific abnormalities. The new ICD-9-CM codes went into effect Oct. 1, 2004.
Since diagnosis codes are updated annually effective every Oct. 1, the ICD-9-CM diagnosis grace period was implemented every Oct. 1 through Dec. 31. The Health Insurance Portability and Accountability Act transaction and code set rule requires use of the medical code set that is valid at the time the service is provided. Therefore, the Centers for Medicare and Medicaid Services eliminated the 90-day grace period for billing discontinued ICD-9-CM codes effective Oct. 1 of this year. Providers must bill using the diagnosis code that is valid for the date of service.
Lisa Miller is CAPhealth policy manager, professional and economic affairs, CAP Division of Membership and Advocacy, Washington, DC.
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