Types of services

The codes in the Pathology and Laboratory section of the CPT manual cover a wide variety of services. The following are the types of services most commonly used:

Superbill/requisition form

Tests are often requested by means of a superbill or requisition form as illustrated in Figure 4-1. Note on the superbill/requisition form that the area under the “Code” column would contain the CPT laboratory code, but for the purposes of this text, the codes have been deleted and you will be removing Figure 4-1 from the text and placing the codes on the form as you work through this chapter. When you are finished with the chapter, you will use the requisition form to complete several coding cases. In the office, the physician would place a check mark in the blank column to the left of the “Code” column as illustrated in Figure 4-2 (see “Test ordered by physician”). The physician would complete the requisition form, or the nursing staff would complete the requisition form per the physician’s direction. The requisition form contains areas for the date and time the test was ordered, the priority of the test, whether the order is for a recurring test that will be conducted several times during the stated time, and any special instructions the physician wants to convey to the laboratory staff regarding the test(s). There is a space to indicate whether the collection of the specimen was conducted in the office or in the laboratory. An example of a physician collecting the specimen would be when the physician performs a spinal tap to aspirate spinal fluid for examination. The fluid then would be sent to the laboratory with a requisition form indicating that the fluid was obtained by the physician in the office, along with directions from the physician for the specific laboratory test(s) requested. The aspiration service performed by the physician is reported separately. An example of the laboratory personnel collecting the specimen would be when the patient takes the General Laboratory Test Requisition to the laboratory where the technician performs the test(s) ordered by the physician. The requisition form is developed by the medical facility to reflect the organization’s most commonly requested laboratory tests. There are also spaces on the requisition form to request tests not listed on the form. The requisition form also has a location for the written indication or diagnosis along with the diagnosis code.

The services in the Pathology and Laboratory section of the CPT manual include the laboratory test only. The collection of the specimen is coded separately. For example, if a patient had a technician in a clinic laboratory withdraw blood by means of a venipuncture, and the blood sample was then analyzed in the laboratory, 36415 is reported for the venipuncture in addition to a code to report the test performed on the blood.

Indicators are written physician orders to the laboratory that set standards. When a test is found to be positive, the physician would want further information about the condition by means of additional laboratory tests. For example, if a routine urinalysis is performed, a culture is performed if a positive bacteria result is found. If a culture is performed to identify the organism, a sensitivity test is performed if the bacteria are of a certain type or count (as predetermined by the medical facility) to warrant the additional laboratory studies. Some indicators are also located on the requisition form. For example, on Figure 4-1

Organ- or disease-oriented panels

The codes in the Organ- or Disease-Oriented Panels are grouped according to the usual laboratory work ordered by a physician for the diagnosis of, or screening for, various diseases or conditions. Groups of tests may be performed together, depending on the situation or disease. For example, during the first obstetric visit, the patient commonly has baseline laboratory tests performed to ensure that appropriate antepartum care can be given. CPT code 80055 describes an obstetric panel that would typically be used for the first obstetric visit. To assign a panel code, each test listed in the panel description must be performed. Additional tests are coded and billed separately. The development of panels saves the facility from having to bill for each test separately, and it is often more economical for the patient.

List each laboratory test separately unless the tests are part of a panel. You cannot report modifier -52 (reduced service) with a panel. For example, if all the tests in the obstetric panel were performed except the syphilis test, you could not report 80055 (Obstetrical Panel) with modifier -52. You would instead list separately each of the tests that were performed with the corresponding CPT code.

Figure 4-3 illustrates the panel codes from the General Laboratory Test Requisition form. The types of codes on the form are based on the requirements of the medical facility. Not all panels are present on the requisition form. Following each panel entry on the requisition form is a list of abbreviations for the tests included in that panel.

Now enter the panel codes onto the General Laboratory Test Requisition form in the blank to the left of the panel test name in the “Panels” section of the requisition form on Figure 4-1. When you have completed all of the activities in this chapter, the superbill/requisition form will have all the necessary codes and will be ready to use in several coding activities from that point on in your coding assignments.

Therapeutic drug assays

Figure 4-4 illustrates the Toxicology for Therapeutic Drugs section from the General Laboratory Test Requisition form. Note the location of the diagnosis number that is placed in the “DX” column. The DX is a number from 1 to 4 that identifies a specific diagnosis code and a written diagnosis statement. For example, if a patient were prescribed phenobarbital for a clonic seizure disorder, the patient’s blood ideally would contain a level of phenobarbital within the therapeutic drug range of 15 to 40 μg per milliliter (toxic range is about 40-100 μg per milliliter). Periodically, the physician would have the phenobarbital level of the patient’s blood assessed to ensure that the level was within the therapeutic range. The physician or the assistant would complete the requisition form by placing the written diagnosis on the form, as illustrated in Figure 4-5, and placing number 1 after “Phenobarbital” in the “DX” column (as illustrated in Figure 4-4) to indicate that the therapeutic drug assay was being performed because of the diagnosis of clonic epilepsy. Sometimes the physician or the assistant would also enter the diagnosis code, and in other instances the medical coder would assign the diagnosis code based on the written description. The code is placed on the line that indicates the diagnosis. For example, if the physician indicated that diagnosis as clonic epilepsy:

ICD-10-CM: Referenced in the Index under the term “Epilepsy, myoclonus, myoclonic—see Epilepsy, generalized, idiopathic.” That entry directs the coder to G40.309.

ICD-9-CM: The Index entry “Epilepsy, clonic” directs the coder to 345.1, which requires a fifth digit. The medical documentation would be reviewed to determine whether the fifth digit “0” (without mention of intractable epilepsy) or “1” (with intractable epilepsy) would be reported. If it is not documented, the coder needs to query the physician as a fifth digit must be assigned to the code.

It is important that the diagnosis and laboratory test correlate to ensure accurate reporting and reimbursement for services provided to the patient.

The drugs are listed by their generic or chemical names, not their brand names. For example, 80162 is for the generic drug digoxin, sold under the brand names of Lanoxin, Purodigin, etc. A current copy of Physician’s Desk Reference for drug reference will be helpful as you report drug assays.

Urinalysis, molecular pathology and chemistry

Many types of tests are located under the Urinalysis, Molecular Pathology, and Chemistry subsections of the CPT manual. Urinalysis codes are for nonspecific tests performed on urine. Chemistry codes are used to report specific tests performed on material from any source (e.g., urine, blood, breath, feces, sputum). For example, a urinalysis using a dipstick (81000-81003) would report the presence and quantity of the following constituents: bilirubin, glucose, hemoglobin, ketones, leukocytes, nitrite, pH protein, specific gravity, and urobilinogen. Any number of these constituents may be analyzed and reported using one code from the range 81000-81003. If the physician ordered an analysis of the urine specifically to determine the presence of urobilinogen (reduced bilirubin) and the exact amount of urobilinogen present (quantitative analysis), you would choose a code from the Chemistry subsection (84580). When assigning codes from the Urinalysis or Chemistry subsection, you need to know:

Urine/stool

Figure 4-6 illustrates the “Urine/Stool” analysis that the medical facility routinely performs. As you read the paragraphs below that refer to these analyses, place the code numbers on Figure 4-1 next to the correct test name.

A nonautomated urinalysis is performed when a dipstick or tablet reagent (a substance that changes color when exposed to another substance) is exposed to urine (81000-81003). The stick or reagent changes color, and that color is compared with a color chart that indicates the various levels of constituents in the sample.

The sample may then be analyzed for any number of constituents in one reading (bilirubin, glucose, hemoglobin, ketones, leukocytes, nitrite, pH, protein, specific gravity, and/or urobilinogen). A manual (a comparison performed by a person without the aid of a machine—nonautomated) urinalysis is reported with 81000 (with microscopy) or 81002 (without microscopy). An automated urinalysis (using a machine) is reported with 81001 (with microscopy) or 81003 (without microscopy).

The “UA, Routine” on the General Laboratory Test Requisition form is an 81003 (automated without microscope) and would represent the most commonly ordered urinalysis. The “Diabetic urine cascade” under “Urine/Stool” on the form is also 81003 and is placed on the form developed by the medical facility because the physicians in the facility often refer to laboratory tests by that name. The “UA with microscopic” on the form is reported with 81001 (automated with microscope). The “Urinalysis, Dipstick, Lab” is 81002 (nonautomated without microscope). Be certain to read the full description of these codes in the CPT manual as you are placing the codes on the requisition form displayed in Figure 4-1.

The Occult Blood is an analysis of a stool sample to detect the presence of blood. Usually the patient takes a kit home and takes from one to three stool samples. The kit is then returned to a laboratory for analysis. Multiple samples improve the accuracy of the test. The test is reported with 82270 for three consecutive collected specimens that are analyzed with a single determination. This CPT code is used even if the patient did not collect all three stool samples. This test is sometimes called a stool guaiac (“gwy-ack”) or FOB (fecal occult blood). Guaiac is the resin of a tree used as a reagent in tests for the presence of blood. Code 82270 reports only the presence or absence of blood in the stool sample (qualitative) and does not report the exact amount of blood present (quantitative). When the physician obtains a diagnostic stool sample during the DRE (digital rectal exam), the laboratory CPT code is 82272.

The routine pregnancy test is reported with 81025 and is located on the form as “Urine HCG” in the Urine/Stool section of the report. HCG stands for human chorionic gonadotropin and is the hormone that the reagent or strip reacts to and the presence of which indicates a positive pregnancy test.

You should now have all the code numbers for the Urine/Stool section entered onto Figure 4-1.

Timed urine

Timed urine tests are illustrated in Figure 4-7. The “Creatinine Clearance” is reported with 82575 and is a kidney function test. The assessment is conducted on a urine sample that is taken over a period of time—usually 24 hours—and calculates the creatinine expelled over that period. In a 24-hour sample, the patient would discard the first urine passed of the day and then collect and refrigerate every urine passed during the next 24-hour period. The “Calcium, Urine, Quant” is a 24-hour sample of urine that is analyzed to determine the amount of calcium expelled over a 24-hour period and is reported with 82340. The “Uric acid” is reported with 84560 and is also a 24-hour urine sample that is analyzed for uric acid. Increased levels of uric acid are indicative of gout or increased risk for kidney stones.

Enter the codes above onto the requisition form in Figure 4-1.

Chemistry

The Chemistry codes can appear to be the most challenging codes in all of the CPT because of the technical language used in the code descriptions. So let’s start at the very beginning on this subsection so you can see that it is not really difficult if you adhere to a few simple steps. The tests in the Chemistry subsection can be from any source (i.e., blood, urine, serum, plasma) unless the code descriptions specifically indicate the source. Therefore, if no source is indicated in the code description, the code covers a sample from any source. An example of a code with a specified source in the code description is 82055 for alcohol by means of any specimen, except breath; 82075 is for a breath alcohol test. An example of a code without a specified source, 82003, is for acetaminophen (Tylenol), and the assessment could be used to report from any source (although the most common would be a dipstick urine test). Therefore, you should always note the source of the sample being tested before assigning a code.

The tests are listed in alphabetical order in the Chemistry subsection, and the tests are located in the CPT index by substance. For example, in the index of the CPT manual, “Acetone” is located in the “As” with the subterm “Blood or Urine” directing you to 82009-82010. The cross-referencing system in the CPT index is especially useful when locating chemistry tests, which are often stated in abbreviation form. For example, for BUN, you are directed by the notes in the CPT index under the entry (BUN) to See Blood Urea Nitrogen; Urea Nitrogen.

Calculations

The “Calculations” section of the report located at the bottom of the Chemistry section (Figure 4-8) contains spaces for the physician to indicate that the technician is to calculate the LDL (low-density lipoprotein) and/or the HDL (high-density lipoprotein). This calculation does not have a separate code because it is not reported separately.

Only gold members can continue reading. Log In or Register to continue

Share this:

• Click to share on Twitter (Opens in new window)
• Click to share on Facebook (Opens in new window)

Like this:

Like Loading...

Related

Related posts:

1. Urinary, male genital, and endocrine systems
2. Integumentary system
3. Anesthesia
4. Evaluation and management services

Stay updated, free articles. Join our Telegram channel

Join