ICD-10 CLINICAL CONCEPTS FOR LABORATORY & CODING GUIDELINES

Step 1: Patient Registration

When the patient walks into a healthcare lab, the front-desk staff collects demographic information of the patients that is used to provide services to the patients and prepare medical bills.

The following data is included in the patient’s demographics;

• Patient identification
• Contact information (phone number & email)
• Date of birth.
• Billing and health insurance details
• List of current and chronic ailments & diagnoses.

Step 2: Confirmation of Medical Coverage

It is the responsibility of healthcare providers to confirm that the patient’s insurance plan covers the prescribed lab testing and medical treatment which is also often called the patient coverage verification process. For this purpose, healthcare administration staff study the coverage policy of the patient and verify if the patient’s coverage plan is eligible for the prescribed procedure.

If the patient’s insurance plan doesn’t cover the prescribed procedure then the patient must be billed for the services. Also, lab billing specialists should charge patients for the copays as well as the deductibles.

Since insurance companies don’t support free healthcare. Usually, insurance only pays a fixed percentage of your healthcare charges. Therefore, your patients are financially responsible for the following expenses;

• Patients pay monthly premiums for their coverage plan whether or not they receive medical care.
• Patients can also be responsible for their entire medical care treatment before the insurance deductible has been met.
• Usually, the insurance company pays between 50 to 90% of your bills, which reduces your copay.
• The patient is responsible for the remaining 10 to 50% of each medical bill.

For example, even after the patient’s deductible has been met, if a doctor’s medical bill is $100 and the patient pays a $25 copay, the insurance only pays the percentage of the remaining amount i.e. $75. Let’s say, if the insurance plan covers 80%, they’ll pay $60 and the patient will also have to pay another $15.

In this example, the patient is responsible for the total cost of $40 and the insurance would pay $60 in the medical bill.

Therefore, lab practitioners require a professional team responsible for ensuring the patient’s eligibility for the coverage plan and their estimate of the patient’s copays.

Step 3: Lab Billing and Coding Services

Once, you recognize the patient’s deductibles and copays then your front desk staff should ask for the payments from patients before providing them lab services. It sheds away the burden of administrative tasks from the shoulders of your employees and helps them maintain efficiency in their workflow.

Once you successfully collect your outstanding deductibles and copays then your medical billing team steps into the picture to collect your reimbursements from the insurance carriers.

Lab billing and coding specialists should prepare charge sheets, apply accurate medical codes, and follow the payer’s timeline to submit medical claims promptly. Either you can hire in-house resources to manage your lab billing and coding services from your office premises. You can also outsource laboratory billing services to a professional lab medical billing company that offers BPO (business process outsourcing) services.

In both cases, you should make sure that your medical billing team is well-versed with lab-specific medical terminologies and procedures. Also, they should have certification or considerable experience in laboratory billing services.

Because if you tend to hire and train your employees to make them experts in lab billing then it can distract your focus from your core responsibilities. Eventually, it will require your time and more resources affecting your efficiency and productivity.

However, if you opt for outsourcing lab billing solutions then you can reduce headcount and cost overhead. Several medical billing companies offer HIPAA-compliant lab billing services keeping your data secure and optimizing your medical billing cycle.

For example, CureCloudMD is a HIPAA-compliant medical billing company that offers reliable, highly transparent, and well-secured lab billing and coding outsourcing services.

In many cases, outsourcing lab billing services helps you reduce your administration expenses by reducing your office’s staff size and incentives for office-based resources.

For example, CureCloudMD is a reliable lab billing company operating all around the USA offering reliable lab billing services at the best prices starting from as low as 2.95% (from the revenue they collect on your behalf after filing your medical claims).

Step 4: Claim Submission

After filing your medical claims, it is the responsibility of lab billing specialists to follow the timelines of each insurance payer. Lab medical billers should file and submit medical claims before the deadline.

However, lab medical billers should scrub claims to review, identify & eliminate mistakes and errors. After clarification, medical billing specialists should submit medical claims to insurance companies if it is also approved by clearinghouses.

Delays in medical claim submission can make your medical claims end up in the form of denials. Elevating claim denials causes increasing account receivables reducing your revenue growth and impacting your practice’s healthcare revenue cycle management negatively.

Step 5: Follow-up With Payers

In case of claim denials or discrepancies, lab billing specialists should follow up with insurance payers and clearing houses for adjudication. Claim adjudication is the process adopted by insurance companies to thoroughly review healthcare bills before reimbursement or payout.

Claim adjudication is a critical step because it decides whether you’re going to get paid for your services a full or partial amount or maybe nothing at all due to claim denial.

Therefore, lab billing specialists should consistently follow up with the insurance companies to resolve all the issues with medical claims timely. It helps them ensure that the healthcare providers get fully paid for the services.

Decoding Medical Coding For Lab Billing Services

As we’ve learned medical billers are required to implement accurate medical codes to prepare clean claims (i.e. medical claims that are 100% accurate & get fully paid at the first attempt of submission).

So let’s dive deep into the world of medical coding and learn why it’s important and how to proceed with medical codes the right way.

What Is Medical Coding?

It is a process to convert patient diagnoses and procedures into universal medical alphanumeric nomenclature.

What Are The 2 Primary Medical Coding Systems?

The two primary coding systems that are used in the medical industry are the International Classification of Diseases, Tenth Revision, Clinical Modification (ICD-10-CM), and the Current Procedural Terminology (CPT).

Who Provides & Maintains Standards For CPT and ICD Coding Systems?

The Centers for Medicare and Medicaid Services (CMS) and the National Center for Health Statistics (NCHS) under the U.S. Federal Government’s Department of Health and Human Services (DHHS) provide the standard guidelines for coding and reporting using the International Classification of Diseases (ICD) codes.

CPT (Current Procedural Terminology) is a coding system developed and maintained by the AMA (American Medical Association) and they are used to describe medical, surgical, and diagnostic services delivered by healthcare professionals.

CPT codes are used to bill outpatient services so the insurance carriers can come to know why their patients are billed.

What Is The Role Of ICD-10-CM and CPT Codes In Lab Billing Services?

ICD-10-CM codes are used to identify diseases, signs, symptoms, abnormal findings, complaints, social circumstances, and external causes of illness and injuries.

The American Medical Association developed the CPT coding system to report medical, surgical, and diagnostic procedures and services.

What Is The Significance Of Medical Codes In Lab Billing Services?

It is critically essential to precisely apply medical codes in medical claims to ensure a smooth workflow of your practice’s healthcare revenue cycle management (RCM).

Also, medical coding specialists should make sure that they are using the most latest code book to prepare charge sheets. Because using incorrect or outdated medical leads can lead to claim denials or delayed payments.

It is the most common challenge of every healthcare lab in the USA to combat claim denials and outstanding reimbursements due to incorrect practices of medical coding.

According to the American Health Information Management Association (AHIMA), incorrect medical coding causes over $36 billion in healthcare waste every year.

What Are The General Medical Coding Guidelines For Laboratory Procedures?

Here are the updated medical codes used for laboratory billing services that became effective as of 2024.

General CPT Coding Rules for Laboratory Procedures

If a lab is reporting CPT codes for individual clinical laboratory procedures then the following rules apply;

• Select the medical code that most precisely identifies the services delivered by the practitioner. If a medical procedure is listed under a particular specialty in the CPT then it doesn’t restrict its use to a specific specialty.
• If you haven’t listed a procedure for a particular analyte then use the method code that precisely identifies the procedure provided to the patient. As a last resort use an unlisted service code (those ending in 99)plus an appropriate description of the procedure.
• You can use the same code multiple times when separate and distinct procedures are used to reach and report separate and distinct goals.
• All laboratory procedures are assumed to be quantitative unless they are specified.
• The material examined can be from any source unless otherwise they are specified in the code descriptor.
• Medical coders can use any method of analysis unless otherwise specified in the code descriptor.
• Clinical information derived from test results by mathematical calculation is considered a part of the test procedure and it isn’t coded or reimbursed separately.

What Are CPT and HCPCS Code Modifiers For Laboratory Billing Services?

CPT and HCPCS code modifiers add two-digit codes to the basic five-digit CPT code. The following modifiers are used to describe unusual circumstances or provide additional information regarding electrophoresis procedures created by CMS (rather than the AMA) to describe situations not covered in the CPT.

-59 Distinct Procedural Service:

This CPT code modifier is used to indicate a test or service that even though the CPT code is the same the test or procedure reported is a distinct and different service.

Example 1:

Apolipoprotein A and B1 are determined on the same date of service. The same CPT code (82172, Apolipoprotein, each) is used to report both assays. In this case, the -59 modifier is used to avoid a denial of the second code as a “duplicate service”. Here’s how these 2 codes are submitted for payment;

• 82172 for Apolipoprotein A
• 82172 -59 for Apolipoprotein B1

Example 2:

For a Multiple Myeloma patient with an Ig G Kappa band on the Immunofixation and determined to be taking the drug daratumumab, in this case, the -59 is applicable for the second Immunofixation (86334) which will be a distinct and different test (Hydrashift 2/4 daratumumab Immunofixation).

-26 Professional Component:

This CPT code modifier is used to identify a physician component of a test (such as interpretation) when it is reported separately. Similarly, in the example mentioned above, the -26 modifier (interpretation of the second, Hydrashift Immunofixation) would be applicable when interpretation is performed.

-90 Reference (Outside) Laboratory:

This CPT code modifier is only used by hospital or reference laboratories to identify tests sent to other laboratories.

-GA Advanced Beneficiary Notice (ABN) on File:

This HCPCS code modifier is used to determine that the provider has notified a Medicare patient that the test performed may not be covered by Medicare and that the patient has to be billed for the services. ABNs must be required by the provider and signed by the patient if the patient is to be billed fr tests or medical procedures that aren’t covered by Medicare.

CPT Codes Associated with Electrophoretic Procedures Protein

Electrophoresis

Medical codes	Electrophoresis Procedures Protein
84165	Protein, electrophoretic fractionation, and quantification, serum
84166	Protein, electrophoretic fractionation, and quantification, other fluids with concentration (eg, urine, CSF)
83916	Oligoclonal immune, (oligoclonal bands)
84181	Protein, Western blot, with interpretation and report
84182	Protein, Western blot, with an immunological probe for band identification, each

Specimen Collection Codes:

Medicare and most other payers allow providers a separate specimen collection charge for drawing or collecting specimens by venipuncture or catheterization, whether the practitioner processes on-site or refers to another lab for analysis.

Medicare allows only one collection fee for each patient encounter, even though multiple specimens may be collected.

The following CPT codes are used to report the routine collection of blood.