Tag: CPT® codes

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The Current Procedural Terminology (CPT)® code set is a medical code set maintained by the American Medical Association through the CPT Editorial Panel. The CPT (copyright protected by the AMA) describes medical, surgical, and diagnostic services and is designed to communicate uniform information about medical services and procedures among physicians, coders, patients, accreditation organizations, and payers for administrative, financial, and analytical purposes.

CPT codes are a critical part of the laboratory billing process. They are similar to ICD-9 and ICD-10 coding, except that it identifies the services rendered rather than the diagnosis on the claim. CPT is currently identified by the Centers for Medicare and Medicaid Services (CMS) as Level 1 of the Healthcare Common Procedure Coding System (HCPCS).

The AMA’s CPT Editorial Panel engages in an ongoing process improvement effort that frequently includes re-examination of the CPT Category I and Category III criteria.

CPT Category I codes are the codes most used in clinical lab and pathology group billing. They are the five-digit numeric codes included in the main body of CPT. These codes represent procedures that are consistent with contemporary medical practice and are widely performed. Codes assigned to this category have met certain criteria including:

  • Procedure or service approved by the Food and Drug Administration (FDA)
  • Procedure or service commonly performed by health care professionals nationwide
  • Procedure or service’s clinical efficacy is proven and documented

The use of the code is mandated by almost all health insurance payment and information systems, including the Centers for Medicare and Medicaid Services (CMS) and HIPAA, and the data for the code sets appears in the Federal Register.

After a clinical laboratory service is provided, diagnosis and procedure codes such as CPT codes are assigned to assist the insurance company in determining coverage and medical necessity of the services. Once the procedure and diagnosis codes are determined, the lab bill enters the laboratory collections/revenue cycle management phase.

ACLA: NCCI Guidelines Are a ‘Step Backwards’

CEO SUMMARY: In a letter to the National Correct Coding Initiative, the American Clinical Laboratory Association (ACLA) raised significant concerns about new language in the policy manuals for Medicare and Medicaid. ACLA said the new NCCI guidelines for molecular and other tests requiring multiple steps for one specimen reduce transparency, increase the administrative burden on

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“I’m from the Government, and I’m here to help.”

Across the nation, clinical laboratories struggle to correctly interpret and follow the new National Correct Coding Initiative (NCCI) guidelines that took effect on Jan. 1. A financial disaster lies ahead for many labs.

“The denials are very high right now and those denials are nationwide,” stated Kyle Fetter, Executive Vice President and General Manager of Diagnostic

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AP Groups Can Protect Revenue, Pathologist Compensation

CEO SUMMARY: Many anatomic pathology groups are watching their revenue decline and margins shrink on the same or greater case volume. These trends make it imperative to have a deeper understanding of the operational and financial variables that contribute to stability in the group’s finances and pathologist compensation. One expert on the financial complexity of anatomic

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Several Big Surprises in 2018’s Top 10 Lab Stories

CEO SUMMARY: This year’s list of the Top 10 Lab Industry Stories for 2018 is dominated by new directives from Medicare and private health insurers, as well as significant decisions by federal courts. Collectively, these developments create new compliance risks for all clinical laboratories and anatomic pathology groups. What is more notable about these top

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In Florida, More Tests Added to UHC’s Decision-Support Program

IN THE FIRST BROAD EXPANSION OF ITS pilot decision-support program for clinical lab testing in Florida, UnitedHealthcare (UHC) will add genetic and molecular tests, drug tests, and pathology procedures, among other assays starting in two months.

On March 1, UHC will expand its laboratory benefit management program in Florida beyond the initial 80 routine anatomical and

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Price Cuts, Long Delays in Payment Are Expected – December 31, 2012

CEO SUMMARY:  In addition to a steep cut in the 88305 CPT code, anatomic pathology laboratories can expect cuts in the payment from Medicare for molecular and prostate biopsy testing. Two national experts in lab billing and reimbursement warn labs to expect confusion in how both public and private payers implement these new policies. Overall,

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