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Pathology/Lab Coding Alert

Ensure Appropriate Payment for Multiple Units of Service Under OCE With Proper Use of Modifiers

- Published on Mon, Jan 01, 2001
Under Medicares revised outpatient code editor (OCE), coders for hospital outpatient pathology and laboratory services will need to use modifiers appropriately to ensure reimbursement for multiple units of service. The national maximum units of service edits are part of the revision to OCE, which limits the number of times per day a specific CPT code can be reported for an individual patient. Although the revised OCE went into effect August 1, 2000, the maximum unit edits have been delayed until the January 2001 OCE update, according to a HCFA memo.

The maximum unit edits have not yet been made public (as of press time), so it is difficult to estimate the impact the edits might have on your practice or laboratory. You can prepare by learning appropriate coding strategies to override the edits for cases that warrant exceeding the maximum units of service. Under the maximum unit edits, billers must learn how to manage coding in order to be reimbursed for all services provided to hospital outpatients, advises Laurie Castillo, MA, CPC, CPC-H, CCS-P, member of the National Advisory Board of the American Academy of Professional Coders (AAPC) and president of its northern Virginia chapter.

When a pathologist or laboratory legitimately provides multiple units of service beyond the maximum established by the OCE, appropriate modifiers must be used to override the maximum unit edits. When reporting multiple units of service, the pathologist must document the repeated tests and support the medical necessity of the procedures.

Use Modifier -59 for Repeat Anatomic Services

To override the maximum unit edits for repeat anatomic pathology services, coders can use modifier -59 (distinct procedural service), Castillo says. HCFA program memorandum A-00-35 indicates that if this modifier is present on a line item of an outpatient claim, the unit edits are not applied. Modifier -59 can be used to indicate that special circumstances warrant reporting the given number of units of a procedure, even if it is more than the maximum determined by HCFA. The multiple units might represent a different site or organ system, separate incision/excision, separate lesion or separate injury, as described in the CPT 2001 direction for modifier -59.

For example, if the maximum units for CPT 88305 (level IV surgical pathology, gross and microscopic examination) are established at 10 (as proposed by HCFA), but it is medically necessary for the pathologist to examine 12 separate specimens at that level, use modifier -59. The line items listed for the first 10 units of service should not be reported with the modifier. However, to be reimbursed for the additional two units, list each of them with the -59 modifier.

Modifier -91 for Multiple Units of Lab Tests

When multiple units of a laboratory [...]

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