This article gives guidance for billing, coding, and other guidelines in relation to local coverage policy for L34037-Flow Cytometry.
General Guidelines for Claims submitted to Part A or Part B MAC:
General Guidelines for claims submitted to Part A or Part B MAC:
Code 88182 applies to the physician professional and facility technical components of DNA ploidy and S-phase analysis of tumor by flow cytometric technique. Use codes 88184 (first marker) and 88185 (each additional marker, beyond the first) to report the facility technical component of flow cytometric immunophenotyping for the assessment of potential hematolymphoid neoplasia.
Flow cytometry interpretation should be reported using CPT codes 88187-88189. Only one code should be reported for all flow cytometry performed on a specimen. Since Medicare does not pay for duplicate testing, do not report flow cytometry on multiple specimens on the same date of service unless the morphology or other clinical factors suggest differing results on the different specimens. There is no CPT code for interpretation of one marker. The provider should not bill for interpretation of a single marker using another CPT code.
Quantitative cell counts performed by flow cytometry are billed using CPT codes 86355, 86356, 86357, 86359, 86360, 86361 and 86367. These codes should not be reported with the flow cytometry interpretation CPT codes 88187-88189 since there is no interpretative service for these quantitative cell counts. Do not report code 88184 or 88185 together with a code in the 86355-86367 series in conjunction with the same laboratory analysis.
Procedure codes may be subject to National Correct Coding Initiative (NCCI) edits or OPPS packaging edits. Refer to NCCI and OPPS requirements prior to billing Medicare. For services requiring a referring/ordering physician, the name and NPI of the referring/ordering physician must be reported on the claim. A claim submitted without a valid ICD-10-CM diagnosis code will be returned to the provider as an incomplete claim under Section 1833(e) of the Social Security Act. The diagnosis code(s) must best describe the patient’s condition for which the service was performed. For diagnostic tests, report the result of the test if known; otherwise the symptoms prompting the performance of the test should be reported.
Advance Beneficiary Notice of Non-coverage (ABN) Modifier Guidelines
An ABN may be used for services which are likely to be non-covered, whether for medical necessity or for other reasons. Refer to CMS Publication 100-04, Medicare Claims Processing Manual, Chapter 30, for complete instructions.
Effective from April 1, 2010, non-covered services should be billed with modifier –GA, -GX, -GY, or –GZ, as appropriate.
The –GA modifier (“Waiver of Liability Statement Issued as Required by Payer Policy”) should be used when physicians, practitioners, or suppliers want to indicate that they anticipate that Medicare will deny a specific service as not reasonable and necessary and they do have an ABN signed by the beneficiary on file. Modifier GA applies only when services will be denied under reasonable and necessary provisions, sections 1862(a)(1), 1862(a)(9), 1879(e), or 1879(g) of the Social Security Act. Effective April 1, 2010, Part A MAC systems will automatically deny services billed with modifier GA. An ABN, Form CMS-R-131, should be signed by the beneficiary to indicate that he/she accepts responsibility for payment. The -GA modifier may also be used on assigned claims when a patient refuses to sign the ABN and the latter is properly witnessed. For claims submitted to the Part A MAC, occurrence code 32 and the date of the ABN is required.
Modifier GX (“Notice of Liability Issued, Voluntary Under Payer Policy”) should be used when the beneficiary has signed an ABN, and a denial is anticipated based on provisions other than medical necessity, such as statutory exclusions of coverage or technical issues. An ABN is not required for these denials, but if non-covered services are reported with modifier GX, will automatically be denied services.
The –GZ modifier should be used when physicians, practitioners, or suppliers want to indicate that they expect that Medicare will deny an item or service as not reasonable and necessary and they have not had an ABN signed by the beneficiary. If the service is statutorily non-covered, or without a benefit category, submit the appropriate CPT/HCPCS code with the -GY modifier. An ABN is not required for these denials, and the limitation of liability does not apply for beneficiaries. Services with modifier GY will automatically deny.
Documentation Requirements
The patient’s medical record should include but is not limited to:
- The assessment of the patient by the ordering provider as it relates to the complaint of the patient for that visit,
- Relevant medical history
- Results of pertinent tests/procedures
- Signed and dated office visit record/operative report (Please note that all services ordered or rendered to Medicare beneficiaries must be signed.)
For claims submitted to the Part B MAC:
All services/procedures performed on the same day for the same beneficiary by the physician/provider should be billed on the same claim.
Claims for Flow Cytometry services are payable under Medicare Part B in the following places of service:
For CPT codes 86355, 86356, 86357, 86359, 86360 and 86361: office (11), independent clinic (49), federally qualified health center (50), rural health clinic (72), and independent laboratory (81);
For CPT code 88182, (global service) office (11), independent clinic (49), and independent laboratory (81);
For CPT codes 88182-TC, 88184 and 88185 (technical services), office (11), independent clinic (49), federally qualified health center (50), rural health clinic (72), and independent laboratory (81);
For CPT codes 88182-26, 88187, 88188 and 88189 (professional services) office (11), inpatient hospital (21), outpatient hospital (22), independent clinic (49), and independent laboratory (81).
For CPT code 92025 (global/technical) POS 15 (mobile unit) is payable under Medicare Part B.