Look for pro-fee denials with non-serum sources
You've always billed for your pathologists' protein and immunofixation electrophoresis interpretations, but suddenly you're getting denied - what gives? The answer is an administrative snafu with CMS payment for CPT 84166 and 86335.
Be on the lookout for claim denials when you bill the professional fee for these codes using modifier -26 (Professional component). Then use the documentation our experts provide to file an appeal with your carrier.
CPT Splits Electrophoresis Codes by Specimen Type
You used to report protein and immunofixation electrophoresis using just two codes regardless of the source: 84165 (Protein; electrophoretic fractionation and quantitation) and 86334 (Immunofixation electrophoresis). But CPT 2005 changed this coding by revising 84165 and 86334 and adding new codes 84166 and 86335. CPT revised the existing codes to specify that the sample source is serum:
CPT also added two new codes for the same test when the lab performs it on fluid sources other than serum:
Law Limits Clinical Lab Interpretation
The problem stems from Medicare's list of covered clinical laboratory interpretive services. "The Medicare Claims Processing Manual (CMS IOM Pub. 100-4), Chapter 12, Section 60E, includes a table of 18 clinical laboratory tests that a pathologist may interpret and report with modifier -26 under conditions that meet the coverage criteria," says Dennis Padget, MBA, CPA, FHFMA, president of DLPadget Enterprises Inc., a pathology business practices publishing company in Simpsonville, Ky. Although the instructions provide that "CMS periodically reviews this list and adds or deletes clinical laboratory codes as warranted," CMS has not updated the list to accommodate the electrophoresis code changes. That's apparently why some carriers won't pay the pathologist's interpretation service.
Pathologists regularly interpret and report protein and immunofixation electrophoresis tests on serum, urine, cerebral spinal fluid (CSF) and other human body fluids. "Since 1992, Medicare Part B contractors have paid for these professional services, irrespective of the type of body fluid that is the specimen," Padget says. "Section 60E nowhere suggests that coverage for code 84165-26 and/or 86334-26 may depend on [...]