Medicare Coding Rules for Clinical Laboratory Services

When coding individual clinical laboratory procedures, the following coding rules apply:
  • (a) Select the name of the procedure that most accurately identifies the service being performed. The listing of a procedure under a particular specialty in the CPT does not restrict its use to that specific specialty.
  • (b) When a procedure for a specific analyte is not listed, use the method code that most accurately identifies the procedure used. As a last resort, use an unlisted service code (those ending in 99) plus appropriate description of the procedure.
  • (c) Procedures that include multiple tests may not be "unbundled" into component procedures. Unbundling is considered an abusive practice by Medicare.
  • (d) Multiple codes may be used to describe a single panel or profile so long as the unbundling rule is not violated.
  • (e) Unless otherwise specified, laboratory procedures are assumed to be quantitative.
Additional coding rules apply to test panels and profiles. If a specific code exists for a given combination of tests, that code must be used. It is considered billing fraud to unbundle a test panel to obtain higher reimbursement if a single code exists that more accurately describes the test panel.

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