Health Information Management

Q/A: Understand requirements for separately reporting CBC with manual differential

APCs Insider, September 16, 2011

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Q: Our MAC recently conducted a focused review based on CERT results concerning complete blood counts (CMC) with manual differential (CPT ® codes 85027 and 85007).
Our physicians write an order for “CBC with diff.” Some of our patients receive chemotherapy so their white blood cell counts are not high enough for an automated differential. The result is basically meaningless, so our protocol is to perform a manual differential to obtain a usable result. In these cases, we don’t charge for the automated differential but we do charge for the manual differential because this is how we obtain results.

We have an order for a differential. However, our MAC/CERT has told us this is incorrect reporting and they are going to recoup payments. Can you offer any insight?

A: A “CBC with diff” correlates to CPT code 85025, which includes an automated differential because most individuals have sufficient counts to obtain results. If a patient’s count is not sufficient, which often occurs after chemotherapy and in some cancer disease processes, the automated differential is meaningless and a manual differential is required.

National Correct Coding Initiative (NCCI) guidelines consider the purpose of performing a manual differential is to confirm the results of the automated differential. Simply, manual differential results give meaning and specificity to results from an automated differential. This process/protocol is perfectly acceptable from a patient care perspective. However, from a billing/reporting perspective, it is considered a confirmatory test that is neither separately reportable nor reportable in place of the test that provided incomplete results.

Physicians must specifically order a CBC with manual differential for coders to report it. Remember that CMS requiresphysicians to express intent for the exact tests/services that are to be done. Internal hospital protocols are not sufficient to support a billable service.

The National Correct Coding Initiative Policy Manual for Medicare Services, Chapter X, §F.1 states:

If a treating physician orders an automated complete blood count with automated differential WBC count (CPT code 85025) or without automated differential WBC count (CPT code 85027), the laboratory sometimes examines a blood smear in order to complete the ordered test based on laboratory selected criteria flagging the results for additional verification. The laboratory should NOT report CPT code 85007 (microscopic blood smear examination with manual WBC differential count) or CPT code 85008 (microscopic blood smear examination without manual WBC differential count) for the examination of a blood smear to complete the ordered automated hemogram test (CPT codes 85025 or 85027)…… If a treating physician orders an automated hemogram (CPT code 85027) and a manual differential WBC count (CPT code 85007), both codes may be reported.

Editor’s note: Denise Williams, RN, CPC-H, director of revenue integrity services at Health Revenue Assurance Associates, Inc., in Plantation, FL, answered this question.

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