Coding update coming next year for Medicare Plus Blue pathology claims

To promote correct coding and assist with payment accuracy, Blue Cross Blue Shield of Michigan will enhance its claim editing process next year for pathology services on Medicare Plus Blue℠ outpatient facility and professional claims.

This coding update focuses on:

• Professional claims for pathology services when an ICD-10 code beginning with R is billed in the primary diagnosis position.
• Outpatient facility claims for pathology services when an R ICD-10 code is the only submitted diagnosis on the claim.

This coding update will exclude claim lines with modifier TC appended.

ICD-10-CM guidance indicates R codes are used for signs and symptoms instead of diagnoses. ICD-10-CM allows these codes in a primary spot when a diagnosis hasn’t been established by the provider. However, if the patient is receiving diagnostic services only (particularly those needing interpretation by a physician), the confirmed or definitive diagnosis should be coded.

In these cases, related signs and symptoms should not be coded as diagnoses. In the pathology realm, once pathology codes are submitted, a definitive diagnosis is typically determined. Therefore, the defined diagnosis should be provided in the first position, as opposed to a symptom-based diagnosis.

Based on the CPT, ICD-10-CM and guidelines from the Centers for Disease Control and Prevention, the pathologist should report a first-listed diagnosis based on the gross/microscopic examination.

The 2022 edition of the ICD-10-CM coding manual, Chapter 18, section B, under “Use of a symptom code with a definitive diagnosis code,” states: “Codes for signs and symptoms may be reported in addition to a related definitive diagnosis when the sign or symptom is not routinely associated with that diagnosis, such as the various signs and symptoms associated with complex syndromes. The definitive diagnosis code should be sequenced before the symptom code.”

Notes:

• If a claim is rejected due to edits that are needed, submit a corrected claim.
• If it’s necessary to submit an appeal, keep in mind that the appeal process won’t change. Continue to submit appeals on the Clinical Editing Appeal Form with the necessary documentation. Also, continue to fax one appeal at a time to avoid processing delays.

None of the information included in this article is intended to be legal advice and, as such, it remains the provider’s responsibility to ensure that all coding and documentation are done in accordance with all applicable state and federal laws and regulations.