Complete Blood Count (CBC) Testing
A complete blood count consists of measuring a blood specimen for levels of hemoglobin, hematocrit, red blood cells, white blood cells, and platelets. Also, a differential white blood cell (WBC) count measures the percentages of different types of white blood cells. This hematology testing is commonly ordered by physicians to diagnose and treat a wide array of disorders such as liver, heart, and pulmonary disease, hemorrhage, dehydration, and infections.
CPT codes representing component tests of CBC testing (with differential WBC testing) include:
85004 Blood count; automated differential WBC count
85007 Blood count; microscopic examination with manual differential WBC count
85008 Blood count; microscopic examination without manual differential WBC count
85009 Blood count; manual differential WBC count, buffy count
85013 Blood count; spun hematocrit
85014 Blood count; hematocrit (Hct)
85018 Blood count; hemoglobin (Hgb)
85032 Blood count; manual cell count (erythrocyte, leukocyte, or platelet)
85041 Blood count; red blood cell (RBC), automated
85048 Blood count; leukocyte (WBC), automated
85049 Blood count; platelet, automated
CPT codes representing the bundled testing services include:
85025 Complete CBC, automated (Hgb, Hct, RBC, WBC, and platelet count) and automated WBC differential – average fee amount – $10 – $20
85027 Complete CBC, automated (Hgb, Hct, RBC, WBC, and platelet count)
National Correct Coding Initiative (NCCI) edits have been established to promote correct coding and prevent inappropriate payments. For example, test codes 85027 and 85004 should not be billed along with code 85025 which represents the bundled testing service.
Based on comments, codes G0306 and G0307 have been established to permit continued billing of common bundled CBC testing services without a platelet count.
G0306 Complete (CBC), automated (Hgb, Hct, RBC, WBC, without platelet count) and
automated differential WBC count
G0307 Complete (CBC), automated (Hgb, Hct, RBC, WBC, without platelet count)
If additional CBC component test(s) are medically necessary, only the medically necessary components (e.g. hemoglobin (Hgb) or hematocrit (Hct) ) should be ordered and performed. Billing modifiers can assist in reporting additional medically necessary CBC component test(s) or bundling testing service for the same patient on the same date of service, such as modifier -91 Repeat clinical laboratory test.
Indications and Limitations
A service or procedure on the “national non-coverage list” may be non-covered based on a specific exclusion contained in the Medicare law; for example, acupuncture; it may be viewed as not yet proven safe and effective and, therefore, not medically reasonable and necessary; or it may be a procedure that is always considered cosmetic in nature and is denied on that basis. The precise basis for a national decision to noncover a procedure may be found in references cited in this policy.
A service or procedure on the “local” list is always denied on the basis that Riverbend GBA does not believe it is ever “medically reasonable and necessary”. Our list of local medical review policy exclusions contains procedures that, for example, are:
experimental
not yet proven safe and effective
not yet approved by the FDA
Reasons for Denial
An advance notice of Medicare’s denial of payment must be provided to the patient when the provider does not want to accept financial responsibility for a service that is considered investigational/experimental, or is not approved by the FDA, or because there is a lack of scientific and clinical evidence to support the procedure’s safety and efficacy.
The service does not follow the guidelines of this policy.
The service is considered:
Investigational
Cosmetic
Routine screening
Dental
Program exclusion
Otherwise not covered
Never medically necessary
Laboratory Fee Schedule
Outpatient hospital lab tests must meet certain criteria to receive separate CLFS payment. If a lab test is the only service provided, or if it is clinically unrelated to the other services provided on the same day and ordered by a different practitioner, the lab HCPCS code must be appended with modifier L1 and reported with outpatient hospital bill type 13X for separate CLFS payment.
If an outpatient lab test is provided with other clinically related services, payment for the lab is packaged into the payment for the primary service reported.
Payment rates under the CLFS are listed by state.
Sole Community Hospital (SCH) Adjustment for Lab A hospital qualifying as a sole community hospital(SCH) is paid 62 percent of the lab fee schedule amount; all other facilities are paid at 60 percent.
To calculate this payment, divide the lab fee schedule amount for your state by 60 percent, then multiply the result by 62 percent:
A = CLFS rate / 0.60
B = A x 0.62 = SCH adjusted rate
For example, complete blood count (CBC) code 85025 has a CLFS amount of $10.58 for the state of Washington. The two-step SCH payment calculation is the following:
10.58 / 0.60 = 17.63 (A)
17.63 x 0.62 = 10.93 (B)
The 62 percent CLFS payment for a Washington state SCH is $10.93 compared to $10.58 for all other facilities.
