Lindsay Posted Thu 25th of July, 2013 14:28:15 PM
Please advise on the rules and regulations surrounding Hospital/technical billing of Tissue Typing. Specifically, I am looking at the below code pairs:
86816: DR/DQ, single antigen
86817: DR/DQ, multiple antigens
86812: HLA typing; A, B, or C (eg, A10, B7, B27), single antigen
86813: HLA typing; A, B, or C, multiple antigens
Currently, we are using these codes to analyze family members to determine if they are an appropriate bone marrow transplant donor for the recipient. While multiple family members are tested, they are all billed to the transplant recipient. CPT 86816 is the initial test done on the recipient; while CPT 86817 is used once the family members are individually tested. The number of units charged for CPT 86817 corresponds to the number of family members tested. Given the below CCI edits, I want to ensure we are billing these services correctly.
CPT codes 86816 and 86817 cannot be billed together due to column two code (86816) is a component of the comprehensive column one code (86817).
CPT codes 86812 and 86813 cannot be billed together due to column two code (86812) is a component of the comprehensive column one code (86813).
Does this mean it is NOT appropriate to bill 86816 and 86817 on the same day even if 86816 is for the recipient and 86817 is for the family members? If so, can you bill the recipient and the family members on separate days? Or does this mean, that if the recipient and family members are tested on the same day you can only bill 86817 for each family member tested?
My other question is whether it is acceptable to bill 86813 and 86817 with multiple units even though they have the word ‘multiple’ in the description? Or are we only allowed to bill it with a unit of one no matter how many family members are tested?
SuperCoder Answered Mon 29th of July, 2013 10:17:24 AM
Generally, a bone marrow transplant recipient has a charge file that chronicles services involving the transplant, including tissue typing services for potential donors. These charges are collected into a revenue class for the transplant, and become part of the Diagnosis Related Group (DRG) for inpatient services.
Many payors have restrictions about which tissue typing tests they’ll cover, often limiting initial testing to A, B, and DR antigens to establish bone marrow transplant donor suitability. That said, you’ll need to get specific information from your payor about billing and coverage issues.
Like blood typing, tissue typing needs to be done only once in a person’s lifetime, so the information is pulled from a bone marrow transplant registry if the potential donor has already been tested.
Know the codes: Assuming that you’re testing the recipient and the potential donors for multiple A, B and DR antigens, you should bill each person’s tests as follows:
• For multiple A and B antigens, report one unit of 86813 (HLA typing; A, B, or C, multiple antigens)
• For multiple DR antigens, report one unit of 86817 (… DR/DQ, multiple antigens)
You should only report one unit of each because the codes describe “multiple antigens.”
The recipient test does not involve single antigens, so you shouldn’t be reporting 86816 (… DR/DQ, single antigen) and 86812 ( …A, B, or C [e.g., A10, B7, B27], single antigen), as you mentioned
Lindsay Posted Mon 05th of August, 2013 15:06:00 PM
***For example, If we bill the 3 donors: Mom, Dad and sister each 1 unit of 86813, it will roll up to 3 units of 86813 on a claim. You are saying that would be correct? And we should also bill the recipient 1 unit of the multiple code 86813 or 86817 depending on which antigens are tested so then it would be 4 units, correct?
Is there ever a scenario where the single antigen code would be billed?
SuperCoder Answered Mon 05th of August, 2013 20:30:10 PM
Regarding donor testing for bone marrow transplant suitability, yes, you should list four units of 86813 if you perform HLA typing for multiple A and B antigens for the recipient and three potential donors. If you also perform HLA typing for multiple DR antigens for each of the same four individuals, you should also list four units of 86817.
Notice: Codes 86813 and 83817 each have a Medically Unlikely Edit (MUE) limitation of one. You will need to follow payer instruction about how to bill the tests for four individuals together on the same day. Remember, you'll need to follow payer rules for bone marrow transplant coverage, which typically involves payment via a facility revenue class.
Your final question was whether there is ever a situation in which you would bill a single antigen. The answer is yes, but not typically in the context of compatibility testing for bone marrow transplant. For instance, you would use 86812 if you're testing for B27 to aid in the diagnosis of ankylosing spondylitis; or you would use 86816 if you're testing for DQ6 to aid in the diagnosis of narcolepsy. A physician would not request either of these single antigen tests as part of a bone marrow transplant compatibility test.