As 2009 ended, we noted that CERT auditors nationwide were stepping up their efforts to improve provider compliance with Complete Blood Count (CBC) coding and billing guidelines.

A recent analysis of Medicare contractors' Comprehensive Error Rate Testing (CERT) Web sites showed an increase in errors due to incorrect coding for CBCs. Because the CBC is one of the most frequently ordered tests, the high volume of claims makes it an easy target for scrutiny.

What do the CERT audits show?

A CBC is a hematology test typically ordered by physicians to diagnose and treat a wide array of physical disorders. The test involves measuring a blood specimen for levels of hemoglobin, hematocrit, red blood cells, white blood cells and platelets. Also included is a differential white blood cell (WBC) count that measures the percentages of different types of white blood cells. The correct CPT code for this test is:

85025: Complete Blood Count, with differential WBC, automated.

Many providers order a CBC, but do not specify that they want the automated WBC differential count. If this is the case, the correct CPT code for this test is:

85027: Complete Blood Count, automated.

CERT record audits show that providers are billing CPT 85025 when documentation only supports the reporting of CPT 85027. CERT reviewers are seeing continuing error rates in the 30 percent range.

What's The Impact?

It sounds like a broken record, but when it comes to CERT, RACs, focused medical review or any other Medicare-type audit, just follow the money. Providers that bill unsupported codes will be overpaid. The Medicare Lab Fee Schedule shows the following current payment rates:

85025................... $11.14

85027....................   $9.27

A $2 differential does not sound like much, but the volume of CBCs performed on a yearly basis is very large, and small dollar amounts multiplied by large volumes can add up very quickly. Besides the risk of overpayments, consider the other intangible and direct costs of incorrect coding such as:

• Dealing with a medical review probe
• Administrative cost of photocopying, record retrieval, etc.
• Filing appeals
• Making claim adjustments

What Should You Do?

1)   Start with the Order

A physician's signature is not required on orders for clinical diagnostic tests (including X-ray, laboratory and others) that are paid on the basis of a clinical laboratory fee schedule, the Medicare Physician Fee Schedule or for physician pathology services. While a physician order is not required to be signed, the physician must document clearly in the medical record his intent that the test be performed. Remind your ordering physicians of the following:

• Tests must be ordered by the physician treating the beneficiary.
• The physician must document clearly in the medical record intent to have the test performed.
• Intent to order a CBC, with or without a WBC differential, must be stated clearly.

2) Code the Service Correctly

To prevent denials, providers should review medical records and physician orders/requisitions before performing and coding services to make sure that what is being ordered, performed and billed all match.

• If the physician has ordered only a CBC, with no mention of a differential, the correct code is 85027.
• If the physician has ordered a CBC with a WBC differential, plus laboratory test results that show automated CBC as well as the differential WBC support, the correct code is 85025.
• Another common error is billing of CBC CPT code 85025 when only hematocrit and hemoglobin laboratory tests have been completed.Providers are advised to make sure they are completing the tests ordered by the physician and only bill for tests actually completed on the bill.
  
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