CPT ’08—tallying what’s new and revised for labs

January 2008
Feature Story

Ayanna Wooding

New pathology and laboratory CPT codes were introduced for CPT 2008 in the organ- or disease-oriented panels, chemistry, immunology, microbiology, and reproductive medicine procedures subsections. CPT coding changes reflecting pathologists’ services can be located in the surgical pathology subsection. Yet by far, the majority of pathology and laboratory-related CPT code changes are reflected in the chemistry subsection. Molecular pathology enthusiasts will be particularly interested in the surgical pathology changes that provide separate codes for manual and laser microdissection services as well as revisions to molecular diagnostic codes 83898, 83900, 83901, and 83908. The following overview will highlight other interesting pathology and laboratory changes for CPT 2008.

Introduction
For the CPT 2008 codebook, the introductory guidelines regarding results, testing, and reports have been deleted from each of the CPT section guidelines. Modified guidelines providing an exemplary relationship between these terms now appear only in the “Instructions for Use of the CPT Book.”

Microbiology
The instructional guidelines following code 87255 and preceding 87260 have been revised to clarify that when separate results are reported for “different species or strain of organisms,” each result should be coded separately.

Code 87500 was created to report determination of vancomycin resistance through infectious agent detection by nucleic acid (DNA or RNA). Five genes can cause vancomycin resistance in enterococci: vanA, vanB, vanC, vanD, and vanE. Both vanA and vanB genes have been shown clinically to have a high resistance to vancomycin and are associated with serious clinical infections. Diseases associated with VRE include endocarditis, bacteremia, urinary tract infections, and meningitis.

Clinical distinction of viral conjunctivitis from bacterial or allergic conjunctivitis can be challenging. However, such determinations lead to the most appropriate treatment. Code 87809 was created for CPT 2008 to allow specific reporting of performance of an immunoassay with direct optical observation test for determination of adenoviral conjunctivitis.

Organ- or disease- oriented panels
The basic metabolic panel is an important panel of chemical tests that is used in a variety of patients, in a variety of clinical settings and points of service, to assess metabolic and other homeostatic issues associated with a host of diseases. Some instrument platforms primarily designed for point-of-care applications do not have the capability to provide total calcium levels; rather, they test for ionized calcium. This analysis is at least as clinically useful as the total calcium level. CPT 2008 provides an accurate way to codify this alternative mechanism of deriving similar clinical information as the traditional basic metabolic panel.

New panel code 80047 has been established to report performance of a basic metabolic panel wherein the calcium analyte is ionized calcium (82330). The existing basic metabolic panel 80048 was revised to clarify that the calcium included in this code is “Calcium, total.” This does not represent a change since total calcium (82310) was already referenced in the panel description. A parenthetical note has also been added that instructs the user not to report code 80047 in conjunction with code 80053 Comprehensive metabolic panel.

Chemistry
Cystatin C is used for the diagnosis of impaired renal function. Code 82610 was developed for CPT 2008 to report quantitative determination of cystatin C.

Code 82272 is intended to describe testing for occult blood by peroxidase activity including from one to three simultaneous determinations. The 2008 revisions made to code 82272 will help to further differentiate it from services reported with code 82270. Code 82272 has been revised to clarify that it is performed for other than colorectal neoplasm screenings. Additionally, the revisions to code 82272 will assist in clarifying the intent of this code as a diagnostic test appropriately reported for use of a commonly available “three test” card ordered for symptomatic reasons. The inclusion of “1-3” in the descriptor clarifies that this code is appropriately reported for assessment of either a single sample obtained from a digital rectal exam or for assessment of a three-test card prepared by the patient.

CPT codes 83036 and 83021 are used to report performance of non-FDA-waived hemoglobin glycosylated (A1c) determinations. However, there are situations in which the determination is complicated by the presence of a hemoglobin variant. Code 83036 is intended to report analysis by chromatography of glycosylated (A1c) hemoglobin. CPT code 83021 is reported for analysis of glycosylated (A1c) hemoglobin detection by chromatographic methodology, when a hemoglobin variant has been identified. In light of potential confusion caused by the potential duplicity of these codes in patients with hemoglobinopathies requiring hemoglobin A1c determination, two cross references have been added for CPT 2008 to direct the user to the appropriate code, based on whether or not a hemoglobin variant has been identified.

Molecular diagnostic codes 83898, 83900, and 83901 were revised to clarify that these codes are intended to be used for “target” amplification procedures. To support these revisions, the phrase “of patient nucleic acid” has been replaced with “target” in the code’s descriptor for codes 83898 and 83900 and add-on code 83901. The phrase “beyond two” has also been added to the code descriptor for code 83901. “Target” refers to a defined nucleic acid region of interest from the original sample that is amplified during an assay using PCR or another amplification technique. The amplified region is then examined using additional molecular diagnostic techniques for a change of one or more nucleotides (for example, oligonucleotide primers flanking a region of interest in nucleic acid and hybridizing to opposite DNA strands will produce a twofold increase in nucleic-acid molecules containing the region of interest in each cycle of PCR).

Code 83908 was revised to clarify its intended use for “signal” amplification procedures. To support this revision, the phrase “of patient nucleic” has been deleted from the code descriptor. “Signal” amplification does not involve nucleic-acid amplification from the original sample. With signal amplification, a complementary probe (the signal) is hybridized to the region of interest (the target) in the original sample. The complementary probe then serves as the source for generating multiple units of signal that can be detected using different means (for example, multiple molecules of an enzyme can be associated secondarily with a branched-chain DNA complex that itself detects a single primary hybridization target, thus producing multiple units of signal from hydrolysis of enzyme substrate).

For more definitive CPT instruction, two parenthetical notes have been added following code 83898 directing the user to codes 83900 and 83901 for multiplex target amplification and to code 83908 for signal amplification. The revised parenthetical note after code 83908 directs the user to codes 83898, 83900, and 83901 for target amplification.

Calprotectin is an important marker useful in distinguishing between irritable bowel syndrome and inflammatory bowel disease. Code 83993 Calprotectin, fecal has been created to report performance of an immunoassay for calprotectin, an indicator of inflammatory bowel disease including Crohn’s disease and ulcerative colitis.

Free beta human chorionic gonadotropin (free beta hCG) is an important assay used for early (first trimester) screening for Down syndrome, trisomy 18, or neural tube defects. For CPT 2008, code 84704 was developed to report free beta human chorionic gonadotropin (free beta hCG).

Immunology and cytopathology
Flow cytometric analyses for lymphocyte subsets (for example, CD5, CD57, CD28, and/or CD38) and other subsets are often clinically required. New code 86356 will allow for reporting of Mononuclear cell antigen, quantitative (eg, flow cytometry), not otherwise specified, each antigen. Code 86486 was established to report skin testing with an unlisted an¬ti¬gen. In conjunction with the introduction of codes 86356 and 86486 for CPT 2008, code 86586 has been de¬leted. For more definitive CPT guidance, a parenthetical note instructing coders not to report codes 88187 through 88189 for the interpretation of 86355, 86356, 86357, 86359, 86360, 86361, and 86367 has been added below code 86356. The same instructional language can be located following code 88189 in the cytopathology subsection. A second parenthetical note has been established within the immunology subsection in conjunction with the deletion of 86586 that appropriately directs users to new codes 86486 and 86356.

A new instructional parenthetical note has been added after code 86703 advising users that modifier -92 may be appended to HIV testing codes 86701–86703 when an HIV antibody immunoassay is performed using a kit or transportable instrument that wholly or in part consists of a single-use, disposable analytical chamber.

Transfusion medicine
The deletion of “antiserum” from 86885 and 86886 code descriptors, the addition of “reagent red cell” to 86885, and “antibody” to 86886 characterize the 2008 revisions made to these antihuman globulin (“Coombs” ) laboratory test codes. Additionally, a new parenthetical note that directs the user to code 86850 for indirect antihuman globulin testing for red blood cell antibody screening can be found below code 86886. A second parenthetical note following code 86886 instructs the user to report code 86870 for indirect antihuman globulin testing for red blood cell antibody identification using reagent red cell panels.

Urinalysis
An instructional parenthetical note has been added after code 81015 to direct the user to report new code 89331 for semen analysis (sperm concentration, motility, and morphology) in urine, for retrograde ejaculation. Code 89331 was created to report assessment of retrograde ejaculate, requiring processing and analysis of an antegrade ejaculate in a urine specimen. The cross reference in the urinalysis subsection has been established as a means to differentiate code 89331 from simple sperm identification in urine.

Surgical pathology
Through the maturation of microdissection technologies commonly used in acquiring diagnostic material for molecular diagnostics, it has become evident that two differing methods exist. CPT 2008 provides two separate codes for reporting microdissection services. For the specific reporting of a manual microdissection service, code 88381 has been created. In this light, revisions to code 88380 Microdissection (ie, sample preparation of microscopically identified target); laser capture reflect further distinction between services. An exclusionary parenthetical note has also been added to the surgical pathology subsection after code 88381 instructing the user not to report 88380 in conjunction with 88381.

Reproductive medicine
Codes 89322 Semen analysis; volume, count, motility and differential using strict morphologic criteria (eg, Kruger) and 89331 Sperm evaluation, for retrograde ejaculation, urine (sperm concentration, motility, and morphology, as indicated) have been introduced for CPT 2008. For the specific reporting of the performance of a sperm evaluation in a retrograde ejaculate that requires the provision and evaluation of semen in a urine sample, CPT code 89331 has been created. Code 89322 was established to report a semen analysis for volume, count, motility, and differential described in code 89320, with an added meticulous microscopic examination of the listed individual sperm characteristics after staining, such as described in “Strict” or “Kruger” morphology evaluation. In support of these changes, code 89320 has been revised by deletion of the term “complete” to indicate performance of a basic semen analysis.

For semen analysis on a concurrent semen specimen, a new parenthetical note after code 89331 directs the user to 89300–89322 in conjunction with code 89331. Along with changes found in the urinalysis subsection, a parenthetical note after code 89331 has been added that directs the user to report 81015 for the detection of sperm in urine. “Semen analysis” has been deleted from the 89321 code descriptor. This revision provides a mechanism for the inclusion in the 89300 through 89322 “Semen analysis” code family.