Dear Donna,
    I work in a reference laboratory.  We bill many insurance companies
across the country.  You should have NO difficulty proving medical necessity
for CPT 88342 for any of the neoplasia ICD-9 codes (140.0 - 239.9).  Other,
non-neoplastic diagnoses MAY prove more problematic as far as reimbursement
is concerned, but you are required to use the ICD-9 code that most
accurately matches the diagnosis.

    However, looking at the ICD-9 codes you listed (and assuming you left
out the decimal point after the 3rd digit), those are all breast cancer
codes.  Is this all related to billing for HercepTest or Herceptin therapy
or other related issues?  If so, that is a whole different ball o' wax, but
you should still be able to document medical necessity.  It sounds like a
communication problem between the lab and billing/insurance.

    I am not familiar with Complynet, nor am I sure to which Laboratory
Medical Review Policy (LMRP) you refer.  Each insurance carrier probably has
their own.


    A summary of the HCFA guidelines to aid in standardizing coding
practices across the USA is printed in the ICD-9 manual as follows:

--Identify each service, procedure, or supply with an ICD-9 code from 001.0
through V82.9 to describe the diagnosis, symptom, complaint, condition, or
problem.

--Identify services or visits for circumstances other than disease or
injury, such as follow-up care after chemotherapy, with V codes provided for
this purpose.

--Code the primary diagnosis first, followed by the secondary, tertiary, and
so on.  Code any coexisting conditions that affect the treatment of the
patient for that visit or procedure as supplementary information.  Do not
code a diagnosis that is no longer applicable.

--Code to the highest degree of specificity.  Carry the numerical code to
the fourth or fifth digit when necessary.  Remember, there are only
approximately 100 valid three-digit codes; all other ICD-9 codes require
additional digits.

Hope some of this is useful.  Best of luck.

Phyllis Davie
pdavie@phenopath.com





on 5/21/01 2:27 PM, Willis, Donna at DonnaWillis@texashealth.org wrote:

> Good Afternoon to All:
> 
> Is anyone out in Histoland using the Complynet system to check for medical
> necessity.  We are having problems in that the only 88342 CPT codes that the
> Laboratory Medical Review Policy (LMRP) are accepting are ones that have
> ICD-9 codes of 1740-1746, 1748-1749, 1750, and 1759.  These are the ICD-9
> codes listed under the LMRP for Her-2/neu.  Is anyone else having their
> 88342 CPT codes rejected by insurance companies?
> 
> Thanks,
> Donna Willis
> Histology Lab Manager
> 
>