Proper Use of Protocols

Noridian Administrative Services, LLC (NAS) has noticed an increase of incorrect coding for Complete Blood Count (CBC) and Urinalysis (UA) laboratory services. Recent Comprehensive Error Rate Testing (CERT) analysis indicates providers are performing additional laboratory services based on a standard written or implied protocol, rather than a patient-specific physician order. Protocol is a routine plan to carry out a study or treatment regimen.

Improper Protocol Examples

  1. White cells or bacteria discovered during a urine test will prompt the laboratory to perform a urine culture based on protocol without a specific order from the physician to perform the culture.
  2. When the laboratory receives an order for CBC the laboratory automatically performs a CBC with differential, although the differential was not specified in the physician order.

CERT errors result when the provider bills the CPT 85025 and the physician order supports only CPT 85027. CERT errors also result when the physician has not ordered a urine culture but one was completed and billed.

Description HCPCS/CPT
Complete Blood Count, automated 85027
Complete Blood Count, with differential WBC, automated 85025
Culture, bacterial, quantitative colony count urine 87086

Best practices demonstrate laboratories should perform and bill the service ordered by the physician.

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