April policy updates
Laboratory
and Pathology Billing Guidelines
Clarified in the opening paragraphs that the policy pertains to codes in the pathology and laboratory section and appendix O of the Current Procedural Terminology (CPT) codebook and the pathology and laboratory
section of the Healthcare Common Procedure Coding System (HCPCS) codebook. Identified the three types of lab panels listed in Appendix O of the CPT codebook. Added PC/TC flag 4 to the list of PC/TC indicator flags. Added to the standing orders
section in the policy that medical records may be requested to validate that a physician order is on file for the lab work.
Medicare
Indicator “Status B” Services Reimbursement
Rewrote the last paragraph in the policy section and embedded a link to the Centers for Medicare and Medicaid National Physician Fee Schedule relative value files.
Modifier
52 – Reduced Services
In the Policy section, expanded on examples where the appending of modifier 52 is not appropriate.
Modifier
53 – Discontinued Services
Added three payment policy references in the cross-reference section. In the policy section, added examples of when Modifier 53 is not appropriate to append to a service. Added a new paragraph in the policy section
to indicate that Modifiers 73 and 74 are not appropriate to append to a professional service, only to an ambulatory surgery center (ASC) facility service.
Modifier
54/55/56 Surgical Care Only/Postoperative Management Only/Preoperative
Management Only
Annual review; no changes.
Modifier 73-Discontinued Outpatient
Hospital/Ambulatory Surgery Center Procedure Prior to Administration of
Anesthesia
Added further clarification on the correct/incorrect use of Modifier 73. Added new paragraph on the correct use of Modifier 74.
Modifier
74-Discontinued Outpatient Hospital/Ambulatory Surgery Center Procedure After
Administration of Anesthesia
Added clarification on the correct use of modifiers 74, 73, and 53 for discontinued services.
Modifier 78 – Unplanned Return to the Operating Room by the Same Physician for a Related Procedure During Postoperative Period
Annual review; no changes.
Personal
Protective Equipment (PPE)
Annual review; no changes.
Unlisted, Non-Specific, and Miscellaneous Procedure
Codes
At the end of the clinical review of unlisted codes section, added a note that additional reimbursement will not be made for surgical techniques, equipment, etc., submitted with an unlisted code. Added the second paragraph under the
multiple unlisted codes section to indicate that if a more specific CPT or HCPCS code more accurately represents one or more of the services rendered that the specific CPT or HCPCS code should be billed rather than an unlisted code.