Article - Billing and Coding: Molecular Pathology and Genetic Testing (A58917)

-59 Modifier; Distinct Procedural ServiceThis modifier is allowable for radiology services and it may also be used with surgical or medical codes in appropriate circumstances.When billing, report the first code without a modifier. On subsequent lines, report the code with the modifier. Under certain circumstances, it may be necessary to indicate that a procedure or service was distinct or independent from other non-Evaluation and Management (E/M) services performed on the same day. Modifier 59 is used to identify procedures/services, other than E/M services, that are not normally reported together, but are appropriate under the circumstances. Documentation must support a different session, different procedure or surgery, different site or organ system, separate incision/excision, separate lesion, or separate injury (or area of injury in extensive injuries) not ordinarily encountered or performed on the same day by the same individual. However, when another already established modifier is appropriate it should be used rather than modifier 59. Only if a more descriptive modifier is unavailable, and the use of modifier 59 best explains the circumstances, should modifier 59 be used.The use of the 59 modifier will be considered an attestation that distinct procedural services are being performed rather than a paneland may result in the request for medical records.Frequent use of the 59 modifier may be subject to medical review.Genomic Sequencing Profiles (GSP)When a GSP assay includes a gene or genes that are listed in more than one code descriptor, the code for the most specific test for the primary disorder sought must be reported, rather than reporting multiple codes for the same gene(s). Reporting multiple codes for the same gene will result in claim rejection or denial.Multianalyte Assays with Algorithmic Analyses (MAAAs) and Proprietary Laboratory Analyses (PLA)A valid PLA code takes precedence over Tier 1 and Tier 2 codes and must be reported if available. Reporting of a Tier 1 or Tier 2 code in this circumstance or in addition to a PLA code is incorrect coding and will result in claim rejection or denial.The results of individual component procedure(s) that are inputs to the MAAAs may be provided on the associated reporting; however, these assays are not reported separately using additional codes. Claims reporting such will be rejected or denied.All MAAAs, including those that do not have a Category I code, may be found in Appendix O of the CPT Manual. When a specific MAAA procedure is not listed in Appendix O, the service must be reported with the unlisted MAAA procedure code 81599. Additionally, when an analysis is performed that may fall within the descriptor of one of the specific MAAA CPT codes, but the proprietary name is not included, the service should be reported with 81599.When reporting CPT code 81599, a description of the analysis (totaling less than 80 characters) must be entered in block 80 (Part A for the UBO4 claim), box 19 (Part B for a paper claim) or electronic equivalent of the claim. Failure to include this information on the claim will result in Part A claims being returned to the provider and Part B claims being rejected. In addition, medical records may be requested when 81599 is billed. The medical record must clearly identify the analysis performed, its analytic validity and clinical utility, and why CPT code 81599 was billed.Date of Service (DOS)As a general rule, the DOS for either a clinical laboratory test or the technical component of a physician pathology service is the date the specimen was collected. In situations where a specimen is collected over a period of two calendar days, the DOS is the date the collection ended. There are some exceptions to the DOS policy. Please refer to the CMS IOM Publication 100-04, Chapter 16, Section 40.8 for complete information related to the DOS policy.Documentation RequirementsAll documentation must be maintained in the patient's medical record and made available to the contractor upon request.Every page of the record must be legible and include appropriate patient identification information (e.g., complete name, dates of service[s]). The documentation must include the legible signature of the physician or non-physician practitioner (NPP) responsible for and providing the care to the patient.The submitted medical record must support the use of the selected ICD-10-CM code(s). The submitted CPT/HCPCS code must describe the service performed.In accordance with CFR Section 410.32, the medical record must contain documentation that the testing is expected to influence treatment of the condition toward which the testing is directed and will be used in the management of the beneficiary's specific medical problem.The medical record must support that the referring/ordering practitioner who ordered the test for a specific medical problem is treating the beneficiary for this specific medical problem. An example of documentation that could support the practitioners management of the beneficiarys specific medical problem would be at least two E/M visits performed by the ordering/referring practitioner over the previous six months.The medical record must include documentation of how the ordering/referring practitioner used the test results in the management of the beneficiarys specific medical problem.The ordering physician/NPP documentation in the medical record must include, but is not limited to, history and physical or exam findings that support the decision making, problems/diagnoses, relevant data (e.g., lab testing, imaging results).The medical record from the ordering physician/NPP must clearly indicate all tests that are to be performed.Documentation requirements of the performing laboratory (when requested) include, but are not limited to, lab accreditation, test requisition, test record/procedures, reports (preliminary and final), and quality control record.