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2012 Buck Step by Step Medical Coding

The Pathology and Laboratory section of the CPT manual is formatted according to what?

type of tests performed

True or False: specimen collection is bundled into most pathology/laboratory codes.

False: specimen collection is reported separately.

Can modifier -51 be used with any pathology/laboratory codes?

No. Always list the procedures multiple times. Append modifier -91 (repeat clinical diagnostic test) as appropriate.

indicator

established by the facility to allow additional labwork to be performed without written orders from physician. eg: urinalysis positive for bacteria is an indicator for urine culture.

If a patient gets most but not all of the tests listed for a panel, can you code the panel with modifier -52?

No. If exact panel is not performed, code different panel or code each test separately.

If a patient gets two panels and one or more tests is listed under both panels, how is this coded?

Do not code both panels. Code the more extensive panel. Code remaining tests separately.

Qualitative testing

determines presence or absence of substance (eg drug) in sample

quantitative testing

determines exact amount of substance (eg drug) in sample

If code 80102 is used to report testing for presence of both alcohol and cocaine, how is this coded?

Report code twice. Append modifier -91 (repeat clinic diagnostic test) to second code.

In the pathology/laboratory section, drugs are listed by their ________ name.

generic

peak level

drug's highest therapeutic concentration

trough level

drug's lowest therapeutic concentration

Evocative/ Suppression Testing

measures the effect of stimulating (evocative) or suppressive agents of chemical components on body

What additional services are often reported with evocative/suppression testing?

1. supplies/drugs (99070 or HCPCS code)
2. physician administration (96365-96379)
3. physician monitoring (E/M)
4. prolonged physician care codes

"limited" clinical pathology consultation

clinical pathologist reviews test but not medical record

"comprehensive" clinical pathology consultation

clinical pathologist reviews test and medical record

block

frozen piece of a specimen

section

slice of a frozen block (piece of a specimen)

clinical pathology consultation

specialist reviews, interprets, and prepares written report on findings at request of attending physician

To correctly code urinalysis, you need to know what 5 variables?

1. method of test
2. reason of test
3. constituents being tested for
4. equipment used
5. number of tests done

Urinalysis codes are for ________ tests performed on urine. Chemistry codes are for ________ tests performed on material from any source.

nonspecific, specific

germline

synonymous with constitutional, often used in reference to the genetic code that is present at birth

What is the difference between Tier 1 and Tier 2 Molecular Pathology procedures?

Tier 1 codes are more commonly performed (eg breast cancer gene screening).

Codes in the Hematology/Coagulation subsection are organized according to what two variables?

method of blood draw and specific test being conducted

hemogram

Written record of complete blood count

Transfusion Medicine codes are also known as what?

blood bank codes

mycology

study of fungi

When using microbiology codes, what modifier is used for multiple specimens or sites?

-59 (distinct procedural service)

There are many similar codes in the microbiology and immunology subsections- what differentiates them?

technique used

Anatomic pathology subsecion codes are use for ________.

postmortem examinations (autopsies)

Cytopathology codes are used to do what?

determine whether cellular changes are present

What is the most common cytopathology service?

Pap smear

Cytogenetics

branch of genetics concerned with cellular abnormalities and pathologic conditions, eg chromosome abnormalities

Where do I find modifiers for cytogenic studies?

Appendix I

What is the unit of measure for surgical pathology codes?

Specimen

What are the two types of pathologic examination?

gross and microscopic

There are ________ levels of surgical pathology

six, based on specimen examined and reason for evaluation

Level I pathology

specimens normally do not need to be viewed under a microscope (eg tooth)

Level II pathology

tissues usually considered normal tissue removed for reason other than disease (eg foreskin)

Level III pathology

specimens with low probability of disease/malignancy (eg gallbladder removed for inflammation)

Level IV pathology

higher probability of malignancy/decision making for disease pathology (eg uterus removed d/t prolapse)

Level V pathology

more complex pathology evaluations (eg uterus removed for reasons other than prolapse or neoplasm)

Level VI pathology

examination of neoplastic tissue or very involved specimens (eg total resection of colon)

BAC

blood alcohol content

Cr

Creatinine

CSF

cerebrospinal fluid

Hct

hematocrit

Hgb

hemoglobin

MRSA

methicillin-resistant staphylococcus aureus

PSA

prostate specific antigen

UA

urinalysis

How do you determine the diagnosis code for labwork?

Code the sign or symptom indicating the reason the test was ordered.

If a more specific diagnosis is confirmed by testing, how is the test ICD-9 coded?

Code for the test result rather than the indications for the test.

If test results are inconclusive, how is this ICD-9 coded?

Code for abnormal findings.

Rh and ABO blood typing are found in what subsection?

Transfusion Medicine (Pathology and Laboratory)

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