For a number of years, CMS has issued and updated a national coding policy manual called "The NCCI Policy Manual for Medicare Services." This is the written part of the Correct Coding Initiative, which also issues enormous Excel spreadsheets that limit the number of units of service of some codes (MUE edits) or block certain codes from being used simultaneously (PTP edits).
See all these forms of instructions online at CMS, here.
Changes in the 2017 Path/Lab policy manual, after the break.
Download the 2017 Zip file of policy instructions at CMS or see the Pathology Chapter in the cloud here. Changes for CY2017 are highlighted in red.
Note I have provided pagination by PDF page; the numbered page is one less. PDF page 3, document pagination written as "X-2." If I comment, I use square brackets [-].
CMS policy prohibits separate payment for testing the SAME analyte by MULTIPLE methods [e.g. by DNA and by IHC].
Changes relative to changing urine drug tox code sets.
Use 81445, 81450, 81455 for targeted genomic sequence analysis, based on organ and/or number of genes. Report only one of these on a single date. [If you test 150 genes, don't report 1-50 code for the first 50, then 50-plus code for the next 100.]
Report only one code for organism testing. If you test CMV by immunoassay, do not also report DNA direct probe. But you may use 1 test for organism identification and 1 other test for drug sensitivity.
Discussion of billing for codes sets for multiplex organism testing (e.g. multiplex respiratory pathogens, 87361-3). Bill only one code set, unless it is medically necessary to test for organisms not found on the multiple panel used.
Further definition of "multiplex immunohistochemistry." If multiple antibodies yield a single reportable result, it is not "multiplex" but rather a 1 unit antibody cocktail.
Similarly, for in situ hybridization, a multiplex procedure yields multiple, individually reported results.
A rather detailed discussion of single versus multiplex versus multiple infectious agent antigen detection. "If a test kit contains a card with five different spots each testing for a different species," one unit of service. If "three different species of that agent using three different test kits," bill three units of service.
Boilerplate text about creation and deletion of urine tox codes; bill only one unit of service of each per day.
Do not inconvenience beneficiaries by having tests drawn and performed on different dates of services "to avoid MUE or PTP edits."
Analyte defined "the entity measured by a test...results of drug tests, genomic sequence, immunology tests, tissue typing, microbiology tests" etc.
Although not new, on page 28 there is a discussion that CMS may describe code ranges (e.g. for genetics) but CPT may include tests that fall, for publishing reasons, outside that code sequence.