CERT Errors Regarding Complete Blood Count (CBC) Services for Jan. 2010

WPS Medicare has noted an increase in the number of Comprehensive Error Rate Testing (CERT) errors related to CPT codes 85025 and 85027. Based on review of documentation, either the test administered or the physician order did not support the service billed to Medicare.

These codes are defined in CPT® 2009 as:

  • 85025 - Complete (CBC), automated (Hgb, Hct, RBC, WBC and platelet count) and automated differential WBC count.
  • 85027 - Complete (CBC) automated (Hgb, Hct, RBC, WBC and platelet count)

In most cases, services were billed under CPT 85025 - with automated differential, but the physician order indicated only "CBC," rather than "CBC w/differential." Without a valid order, the medical necessity of the billed code billed is not supported, and the Medicare payment must be adjusted to reflect the ordered test. In other cases, CPT 85027 was billed, while the results and physician orders supported CPT 85025.

There is a second documentation issue that contributes to errors on the above-mentioned codes. WPS has observed that documents such as the Fee Ticket, Lab Order Form or Super Bill, often did not differentiate between "CBC" and "CBC w/Differential." They encourage you to review your lab ordering system, or forms, to determine if they specifically include both a CBC and a CBC w/differential. If your documents do not list both options, confusion may result because the lab may not be able to determine which test the physician ordered. This could result in overpayments or underpayments for claims submitted for these services.

It is imperative that coders understand the definition of each service to ensure the appropriate code is billed to Medicare, and that the code is based upon the service ordered and rendered. It is also crucial that the ordering physician accurately document his or her intent for the specific service requested, to support the medical necessity. Services billed to Medicare that are not appropriately documented and medically necessary, will result in recoupment of Medicare payments.

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