What is the Problem with CBCs?

“Billing for services while operating in an environment of audit” has become my favorite catch phrase for 2010. It has been just over 7 years since the AMA updated the CPT descriptions for hematology procedures adapting the codes to current reporting practice of the clinical laboratory. Still in 2010, one of the most frequently billed outpatient tests continues to be incorrectly or inappropriately reported for reimbursement.

 Considering the fact that services billed by the clinical laboratory have been the focus of audits conducted by the OIG, regional payers for Medicare & Medicaid and commercial payers for 10 or more years it surprises me that the WPS Part B Communiqué distributed this week through MediRegs e-mail alert of What’s New included a CERT Error Report for CPTs 85025 and 85027. (Note: Using MediRegs Audit & Revenue Resource Center, I used Code Explorer and searched for CPT code 85025. From the search results, I followed a link for Coding Guidance relevant to the billing of this code. Under this link, I found the CERT Error Reports (10 issued in 2008-2009) that provided commentary regarding unsupported charges for codes 85025 and 85027.) In today’s automated world of processing hematology specimens, when a request is for CBC with differential the appropriate CPT will most likely be 85025; however, there are exceptions to this rule of thumb and the AMA CPT codes do allow laboratories to apply codes based on the individual scenario. The key is in understanding and applying the guidelines for correct coding based on documentation found in the order and the final results reported. For example:

1. The physician orders a CBC (and does not specify a differential is to be performed). The laboratory processes the specimen and reports results of the automated hemogram. YOU BILL 85027!
   
   • The report includes abnormal results for hemoglobin, hematocrit and WBC;
   • The doctor follows with a request for differential to be performed on the same sample;
   • The laboratory revises the report to include the automated differential.
   • YOU NOW BILL 85004 (in addition to 85027);
   • The national correct coding initiative edits the combination of 85027 and 85004 as “Misuse of CPT” indicating that the laboratory has unbundled the comprehensive CPT 85025. Use of a modifier is not allowed. You must revise the code selection.
   • YOU CORRECTLY BILL 85025!

2. The physician orders a CBC with differential (the order does not specify if the differential is to be automated or by manual method). The laboratory standard of practice is to perform the CBC with automated differential and validate abnormal differential flags with a manual differential. YOU BILL 85025 and 85007
   
   • The national correct coding initiative edits this CPT combination as “Misuse of CPT” indicating that the laboratory has unbundled the comprehensive CPT 85025. Use of a modifier is not allowed. You must remove CPT 85007.
   • YOU CORRECTLY BILL 85025!

The determination to perform and bill for the differential is dependent on the physician order. If the physician request is for CBC, the documentation supports billing of CPT 85027. Only when the physician requests CBC with differential will documentation support billing of either 85025 or 85027 with 85007. The National Correct Coding Initiative allows the billing of only one differential per date of service.

Written by Robin Miller Zweifel, BS, MT(ASCP)