While several laboratory sections are very straightforward in coding and billing, such as chemistry and hematology, the micro lab has numerous “add on” procedures that are routinely performed to complete the culture report. Frequently, add on charges are never captured.

Additional identification procedures, serological typing of pathogens, and susceptibility procedures are entered after at least 24-hours post culture setup and, if forgotten, results in substantial loss in reimbursement. This loss is often as much as 66 percent of the potential revenue.

There are several reasons – some process driven, others human errors— for not submitting charges in a timely manner. Actually, microbiology has more in common with surgical pathology processes and time lines than it does with the more automated, fully interfaced laboratories, but that is a topic for a future column.

One of the processes that microbiologists cannot fight (or understand) is the National Correct Coding Initiative (CCI) edits for multiple cultures performed on a single date of service. Why a blood culture (times three) has a CCI edit with a wound culture or a wound culture has an edit with a urine culture is a mystery—and perhaps one of those rules where we just cannot always use logical thought processes when understanding federal agencies.

The typical outpatient needing bacterial cultures on any given date of service will usually have only one “source” cultured. However, it is not unusual for outpatient surgery patients, observation patients, emergency room patients, or even inpatients to have more than one culture on a single date of service.

Table 1 shows the current code pairs with edits for Blood Cultures (87040), Wound Cultures (87070) and Urine Cultures (87088).

The majority of aerobic cultures (identified with CPT codes 87045, 87046, 87070, 87081, or 87088) can have colonies (think isolates) visible in 24-to-48 hours. Once growing, the isolates are evaluated by the microbiologist who may perform a battery of identification procedures based on the colony morphology, source of the specimen, potential pathogens, and presumptive identification. Even if the identification procedure results in negative results, i.e., “non-pathogen,” the procedure was warranted, documented and necessary for the report conclusion.

These add-on charges, such as CPT code 87077 (aerobic identification) and if the organism is a genus with serotypes like Streptococcus, CPT 87047 (serological typing, per antisera) used in the testing are eligible to be billed. Almost every organism identified has susceptibility testing (CPT 87186) as well.

Table 2 is from the Clinical Laboratory Fee Schedule. With the average national payment used, we can estimate a financial impact for complete coding of “positive” cultures.

As an example, imagine that a patient arrives in the emergency room with sporadic fever of approximately 103 degrees. The patient also has an open sore on his left leg. Three blood cultures are drawn 30-minutes apart as well as a wound culture from the leg ulcer. Forty-eight hours later the wound culture had a heavy growth of a gram negative rod, but all blood cultures were negative.

The following CPT codes were noted on the bill (which was “dropped” the next day): 87040 x 3, 87070. The anticipated reimbursement for the cultures based on the claim is $44.39 (87040 x 3 = $14.79 x 3). The total amount of the “lost” reimbursement is $34.74 (87070 x 1 (if 59 modifier not used) + 87077 x1 + 87186 x1 = $12.34 + 10.02 + 12.38.

If the same type scenario is typical, and the micro lab has approximately 10 positive cultures per day that are not “completely” billed, then annual revenue loss is $81,760 solely for 87077 and 87186 ($22.40 each culture and 10 cultures per day for one year).

Betty Hatten, CPC-H, MHS, MT(ASCP), is a manager in healthcare services at HORNE LLP. Her primary responsibilities include oversight of the chargemaster assessment and maintenance team, as well as providing charge capture audits, performance improvement assessments, and focused compliance reviews for laboratories, diagnostic services, physical therapy, occupational therapy, speech therapy, sleep labs, respiratory therapy, emergency departments, inpatient and outpatient billing and coding, physician and physician office staff education. She is a member of the American Health Information Management Association and the American Academy of Professional Coders. She can be reached at betty.hatten@horne-llp.com

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