Healthcare Fraud Shield’s Latest Article: 2021 Changes to Pathology and Laboratory Codes

18 Dec


However, let us not overlook all the new Pathology and Laboratory codes for 2021.  The bulk of new codes are in the Pathology & Laboratory section of the Current Procedural Terminology (CPT) book.   

There are hundreds of code changes and a lot of the focus is on the Evaluation & Management codes. The most revisions occurred in the Evaluation & Management and Integumentary areas. The deletions concentrated mostly around the Medicine section as well as Evaluation & Management codes.


Pathology & Laboratory Changes
There are several new codes added to therapeutic drug assays. A therapeutic drug assay measures or tracks the level of a drug that a patient is taking whether it is prescribed or over the counter.   The type of specimen collected may be blood, serum, plasma or cerebrospinal fluid.     The new therapeutic drug assay codes include1:

  • 80143 – Acetaminophen
  • 80151 – Amiodarone
  • 80161 – -10,11 -epoxide
  • 80167 – Felbamate
  • 80181 – Flecainide
  • 80189 – Itraconazole
  • 80193 – Leflunomide
  • 80204 – Methotrexate
  • 80210 – Rufinamide
  • 80179 – Salicylate

Prior to these new codes, the appropriate code to bill was CPT 802992 which is an unlisted code. Unlisted codes are more prone to fraud, waste, and abuse as they are not specifically defined.   In our experience, these unlisted codes become the hiding place for services not rendered or for testing that may be experimental, investigational, and/or unproven.


What to look for?
With the new more explicitly identifiable codes, provider may still attempt to use the unlisted code to mask the test being performed (if performed at all!) With that in mind,

  • Continue to look for excessive billing of 80299 per day, per member
  • Look for repeat billing on the same member
  • Look for patterns by LOB/Product Type or Group
  • Look for excessive billing of any of the new codes
  • Review each member’s pharmacy data to see if corresponds to the tests being performed.

If you have any questions, please do not hesitate to reach out to SIU@hcfraudshield.com.


REFERENCES:

[1,2] AMA CPT Book

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