Health Information Management

Q/A: Correct orders for lab services

APCs Insider, January 8, 2010

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Q: All of a sudden we are receiving recoupments for some lab work we performed. The information from our FI/MAC says that there was no order for the CBC with diff. Our internal lab protocol is written to reflect that when a physician orders a CBC, a CBC with diff is performed. It has been through the appropriate internal approvals and the physicians have agreed. What is the deal?
A: The FI/MACs are performing CERT (Comprehensive Error Rate Testing) reviews. One of the hot spots right now centers on having complete orders for all services provided.
When the physician orders a CBC, this test should be reported with CPT code 85027 (blood count; complete [CBC], automated [Hgb, Hct, RBC, WBC and platelet count]). Your internal lab protocol also performs an automated differential, which would be reported with CPT code 85025 (blood count; complete [CBC], automated [Hgb, Hct, RBC, WBC and platelet count] and automated differential WBC count).
Although the appropriate people within you facility have approved your internal protocol, this is not applicable to how Medicare or other payers process claims. From that standpoint, the physician has ordered a specific test, but the lab performed and reported a different test. Payers don’t have a copy of your internal protocol or all the reasons that the decision was made to handle this situation in this manner. What they see is that there is no order for the test to be performed because the physician intent was for a “plain” CBC; therefore, the CBC with diff is a non-covered, non-reimbursable service. The test that the physician orders is the test that the lab should perform and report.
If the physician intends for a CBC with diff to be performed, that is what the order should read. If your order form is preprinted, then you should include all options on the order form for the physician to indicate the test intended. In this scenario, you would list a CBC, a CBC with diff, and a CBC with manual diff. The physician would then check off the test he or she wants for the patient. If the orders are hand written, the physician has to specify “CBC with diff” in order to show his or her intent.

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