CHAPTER X - PATHOLOGY / LABORATORY SERVICES

CHAP10-CPTcodes80000-89999Revision Date: 1/1/2021CHAPTER XPATHOLOGY / LABORATORY SERVICESCPT CODES 80000 - 89999FORNATIONAL CORRECT CODING INITIATIVE POLICY MANUALFOR MEDICARE SERVICESCurrent Procedural Terminology (CPT) codes, descriptions andother data only are copyright 2020 American Medical Association.All rights reserved.CPT is a registered trademark of the American MedicalAssociation.Applicable FARS\DFARS Restrictions Apply to Government Use.Fee schedules, relative value units, conversion factors,prospective payment systems, and/or related components are notassigned by the AMA, are not part of CPT, and the AMA is notrecommending their use. The AMA does not directly or indirectlypractice medicine or dispense medical services. The AMA assumesno liability for the data contained or not contained herein.Revision Date (Medicare): 1/1/2021X-1

Table of ContentsChapter X . X-3Pathology and Laboratory Services CPT Codes 80000 - 89999 . X-3A.Introduction .X-3C.Organ or Disease Oriented Panels .X-7B.D.E.F.G.H.I.J.K.Evaluation & Management (E&M) Services .X-5Evocative/Suppression Testing .X-7Drug Testing .X-8Molecular Pathology .X-8Chemistry .X-10Hematology and Coagulation .X-11Immunology .X-13Transfusion Medicine .X-13Microbiology .X-14L. Anatomic Pathology (Cytopathology and Surgical Pathology).X-16M.N.Medically Unlikely Edits (MUEs) .X-20General Policy Statements .X-27Revision Date (Medicare): 1/1/2021X-2

Chapter XPathology and Laboratory ServicesCPT Codes 80000 - 89999A.IntroductionThe principles of correct coding discussed in Chapter I apply tothe Current Procedural Terminology (CPT) codes in the range80000-89999. Several general guidelines are repeated in thisChapter. However, those general guidelines from Chapter I notdiscussed in this chapter are nonetheless applicable.Physicians shall report the HCPCS/CPT code that describes theprocedure performed to the greatest specificity possible. AHealthcare Common Procedure Coding System/Current ProceduralTerminology (HCPCS/CPT) code shall be reported only if allservices described by the code are performed. A physician shallnot report multiple HCPCS/CPT codes if a single HCPCS/CPT codeexists that describes the services. This type of unbundling isincorrect coding.HCPCS/CPT codes include all services usually performed as partof the procedure as a standard of medical/surgical practice. Aphysician shall not separately report these services simplybecause HCPCS/CPT codes exist for them.The Centers for Medicare & Medicaid Services (CMS) oftenpublishes coding instructions in its rules, manuals, andnotices. Physicians must use these instructions when reportingservices rendered to Medicare patients.The "CPT Manual" also includes coding instructions which may befound in the “Introduction”, individual chapters, andappendices. In individual chapters, the instructions may appearat the beginning of a chapter, at the beginning of a subsectionof the chapter, or after specific CPT codes. Physicians shouldfollow "CPT Manual" instructions unless the CMS has provideddifferent coding or reporting instructions.Specific issues unique to this section of CPT are clarified inthis chapter.Pathology and laboratory CPT codes describe services to evaluatespecimens (e.g., blood, body fluid, tissue) obtained frompatients in order to provide information to the treatingphysician.Revision Date (Medicare): 1/1/2021X-3

Generally, pathology and laboratory specimens are prepared,screened, and/or tested by laboratory personnel with apathologist assuming responsibility for the integrity of theresults generated by the laboratory. Certain types of specimensand tests are reviewed or interpreted personally by thepathologist. CPT coding for this section includes few codesrequiring patient contact or Evaluation & Management (E&M)services rendered directly by the pathologist. If a pathologistprovides significant, separately identifiable face-to-facepatient care services that satisfy the criteria set forth in theE&M guidelines developed by the CMS and the AMA, a pathologistmay report the appropriate code from the E&M section of the "CPTManual."CMS policy prohibits separate payment for duplicate testing ortesting for the same analyte by more than one methodology. (Seedefinition of analyte in Section M (General Policy Statements),subsection 2.) If, after a test is ordered and performed,additional related procedures are necessary to provide or verifythe result, these would be considered part of the ordered test.For example, if a patient with leukemia has a thrombocytopenia,and a manual platelet count (CPT code 85032) is performed inaddition to the performance of an automated hemogram withautomated platelet count (CPT code 85027), it would beinappropriate to report CPT codes 85032 and 85027 because theformer provides verification for the automated hemogram andplatelet count (CPT code 85027). As another example, if apatient has an abnormal test result and repeat performance ofthe test is done to verify the result, the test is reported asone unit of service rather than 2.By contrast, some laboratory tests (if positive) requireadditional separate follow-up testing which is implicit in thephysician’s order. For example, if an RBC antibody screen (CPTcode 86850) is positive, the laboratory routinely proceeds toidentify the RBC antibody. The latter testing is separatelyreportable. Similarly, if a urine culture is positive, thelaboratory proceeds to organism identification testing which isseparately reportable. In these cases, the initial positiveresults have limited clinical value without the additionaltesting. The additional testing is separately reportablebecause it is not performed to complete the ordered test.Furthermore, the ordered test (if positive) requires theadditional testing in order to have clinical value. This typeof testing is a category of reflex testing that must bedistinguished from other reflex testing performed on a positivetest result which may have clinical value without additionalRevision Date (Medicare): 1/1/2021X-4

testing. An example of a latter type of test is a serum proteinelectrophoresis with a monoclonal protein band. A laboratoryshall not routinely perform serum immunofixation or serumimmunoelectrophoresis to identify the type of monoclonal proteinunless ordered by the treating physician. If the patient has aknown monoclonal gammopathy, perhaps identified at anotherlaboratory, the serum immunofixation or immunoelectrophoresiswould not be appropriate unless ordered by the treatingphysician.If a laboratory procedure produces multiple reportable testresults, only a single HCPCS/CPT code shall be reported for theprocedure. If there is no HCPCS/CPT code that describes theprocedure, the laboratory shall report a miscellaneous orunlisted procedure code with a single unit of service.B.Evaluation & Management (E&M) ServicesMedicare Global Surgery Rules define the rules for reporting E&Mservices with procedures covered by these rules. This sectionsummarizes some of the rules.All procedures on the Medicare Physician Fee Schedule areassigned a global period of 000, 010, 090, XXX, YYY, ZZZ, orMMM. The global concept does not apply to XXX procedures. Theglobal period for YYY procedures is defined by the MedicareAdministrative Contractor (MAC). All procedures with a globalperiod of ZZZ are related to another procedure, and theapplicable global period for the ZZZ code is determined by therelated procedure. Procedures with a global period of MMM arematernity procedures.Since National Correct Coding Initiative (NCCI) Procedure-toProcedure (PTP) edits are applied to same day services by thesame provider to the same beneficiary, certain Global SurgeryRules are applicable to the NCCI program. An E&M service isseparately reportable on the same date of service as a procedurewith a global period of 000, 010, or 090 days under limitedcircumstances.If a procedure has a global period of 090 days, it is defined asa major surgical procedure. If an E&M service is performed onthe same date of service as a major surgical procedure for thepurpose of deciding whether to perform this surgical procedure,the E&M service is separately reportable with modifier 57.Other preoperative E&M services on the same date of service as amajor surgical procedure are included in the global payment forRevision Date (Medicare): 1/1/2021X-5

the procedure and are not separately reportable. The NCCIprogram does not contain edits based on this rule because MACshave separate edits.If a procedure has a global period of 000 or 010 days, it isdefined as a minor surgical procedure. In general, E&M serviceson the same date of service as the minor surgical procedure areincluded in the payment for the procedure. The decision toperform a minor surgical procedure is included in the paymentfor the minor surgical procedure and shall not be reportedseparately as an E&M service. However, a significant andseparately identifiable E&M service unrelated to the decision toperform the minor surgical procedure is separately reportablewith modifier 25. The E&M service and minor surgical proceduredo not require different diagnoses. If a minor surgicalprocedure is performed on a new patient, the same rules forreporting E&M services apply. The fact that the patient is“new” to the provider is not sufficient alone to justifyreporting an E&M service on the same date of service as a minorsurgical procedure. The NCCI program contains many, but notall, possible edits based on these principles.For major and minor surgical procedures, postoperative E&Mservices related to recovery from the surgical procedure duringthe postoperative period are included in the global surgicalpackage as are E&M services related to complications of thesurgery. Postoperative visits unrelated to the diagnosis forwhich the surgical procedure was performed unless related to acomplication of surgery may be reported separately on the sameday as a surgical procedure with modifier 24 (“UnrelatedEvaluation and Management Service by the Same Physician or OtherQualified Health Care Professional During a PostoperativePeriod”).Procedures with a global surgery indicator of “XXX” are notcovered by these rules. Many of these “XXX” procedures areperformed by physicians and have inherent pre-procedure, intraprocedure, and post-procedure work usually performed each timethe procedure is completed. This work shall not be reported asa separate E&M code. Other “XXX” procedures are not usuallyperformed by a physician and have no physician work relativevalue units associated with them. A physician shall not reporta separate E&M code with these procedures for the supervision ofothers performing the procedure or for the interpretation of theprocedure. With most “XXX” procedures, the physician may,however, perform a significant and separately identifiable E&Mservice that is above and beyond the usual pre- and postRevision Date (Medicare): 1/1/2021X-6