Medicare laboratory fee schedule and CPT code updates - Brief Article

Medical Laboratory Observer, Jan, 2001 by C. Anne Pontius

The new CPT codes and Medicare 2001 laboratory fee schedule are available to users. CPT codes are the copyright of the AMA and can be purchased from a variety of resources. The Medicare 2001 laboratory fee schedule can be downloaded from www.hcfa.gov/stats/pufiles.htm#rvu. You can select an Excel spreadsheet, text, or comma delimited formats. If the Excel spreadsheet is downloaded, you can move the descriptors located in the last column to the first column. This makes the chart easier to read because the descriptors will be next to the CPT codes.

There is no annual update to the fee schedule, which remains at 74% of the median. This was mandated by the Balanced Budget Act of 1997.

The differences in CPT codes for laboratory services from 2000 to 2001 include 56 additions, 17 deletions, and more than 60 description revisions. The Program Memorandum for Intermediaries/Carriers (Transmittal AB-00-109) instructs those groups how to implement the 2001 Medicare Fee for laboratory services.

One HCFA official stated that there were too many new codes this year, and therefore it was impossible to ensure that every crosswalk (links to older codes) for payment purposes was as appropriate as it could be. The HCFA official implied that nothing could be done about the 2001 reimbursements. Comments concerning the 2001 fee schedule can be submitted by August 1, 2001. Comments must be in written format and include clinical, coding, and pricing information. Comments received after that time or not in the appropriate format cannot be considered for the 2002 laboratory fee schedule. Comments should be submitted to: HCFA, Division of Acute Care, Center for Health Plans and Providers, Mailstop: C4-07-07, 7500 Security Boulevard, Baltimore, Maryland 21244-1850.

The manufacturers of devices affected by the 2001 changes recognize that the payment crosswalks are not reflective of costs. Therefore, they will be diligently working individually and through the Advanced Medical Technology Association (AdvaMed) to inform HCFA of appropriate reimbursements. The manufacturers encourage end users of their products to write HCFA and express concerns about tests they feel are not appropriately reimbursed.

Specific CPT concerns

Three tests rolled into one. Users of the Affirm VP III Microbial Identification Test by Becton Dickinson (Franklin Lakes, NJ), prepare for a shock when you seek reimbursement in 2001. There is a new code, 87800--infectious agent detection by nucleic acid (DNA or RNA), multiple organisms; direct probe(s) technique that represents testing for all multiple organisms with one specimen. The reimbursement was crosswalked to 87797, which pays for one organism only. Before 2001, Candida (87480), Gardnerella (87510), and Trichomonas (87797) could each be billed separately, which when totaled paid $83.13 (National Limitation Amount or NLA). Now the payment is for one test only, which amounts to $27.71.

Glucose gap-filling. Of particular concern is the requirement that carriers must gap-fill CPT 82962--glucose, blood by glucose device(s) cleared by the FDA specifically for home use. These devices are commonly used in physician's offices. Reimbursement had been crosswalked to the quantitative glucose test, which paid $4.37 (NLA). The Program Memorandum (AB-00-108) states that HCFA felt that its crosswalk was erroneous. Therefore, carriers have been instructed to gap-fill 82962. This means they will pay according to the charges submitted by providers.

When submitting a charge to Medicare for 82962, it is important to consider all the costs incurred for the service. Carriers have been instructed that their gap-filling should consider, as appropriate, the costs of professional and clerical labor, device amortization, supplies, and overhead. If all labs submit low costs, then they can expect low payments.

Wet and dry mounts. The code 87211--smear, primary source, with interpretation; wet and dry mount, for ova and parasites has been deleted in 2001. The CPT book directs providers to use 87177--ova and parasites, direct smears, concentration and identification. This code is very misleading. The 87177 pays $12.30, which is substantially more than 87211, which paid $7.15. But if you were (are) using 87211 to represent a saline prep, then the replacement code should be 87210, which has been redefined in 2001 to specifically include saline and has dropped the "special stain" requirement.

Urine cultures. The urine culture code 87087--culture, bacterial, urine; commercial kit has been deleted, and the CPT code book recommends using 87088, which now reads as culture, bacterial; with isolation and presumptive identification of isolates, urine.

Pinworm examination. The new code 87172 has been established for a pinworm examination.

Deleted codes. There is a 3-month grace period for deleted codes. Therefore, beginning April 1, 2001 deleted codes should no longer be billed. This can be confusing because the laboratory fee schedule contains almost all of the deleted codes. It would be nice if the fee schedule could indicate tests that have been deleted (hint-hint to any federal employee readers).