Bone marrow cases can be quite lengthy and include many separate potential areas that generate charges. Appropriate supporting documentation in each part of the case is necessary for complete charge capture. APS’ routine audit program for clients has uncovered many errors that can affect revenue in the form of charges billed or by putting revenue at risk due to incomplete documentation. The following outlines common bone marrow case components and required documentation or tips to support the charges:
Bone Marrow Case Component | Documentation should include: |
When the pathologist performs the procedure | * “Procedure performed by Dr. ____” * Aspirate/Core biopsy performed through same incision or separate sites * Aspirate only or core biopsy only
|
Peripheral Blood Smear | * Indicate if interpretation is performed by pathologist |
Aspirate Smear | * Chargeable whether or not a differential cell count is part of the interpretation |
Aspirate Clot Section | * Must be identified as a separate specimen from the aspirate smear, and is separately chargeable
|
Bone Marrow Biopsy | * Preparation, examination, and diagnosis of the biopsy |
Non-intraoperative touch prep on core biopsy | * TP on the core biopsy (not the aspirate) can be billed * Commercial carriers only, can’t be billed to Medicare
|
Decalcification | * Must be documented to be billed * Billed once per specimen even if done on multiple blocks
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Special Stains | * Documented each stain per block * Billed per block, not per specimen |
Immunohistochemistry stains, qualitative | * Document each with positive or negative result * Billed once per specimen, per antibody |
Immunohistochemistry stains, quantitative | * Document each with numerical result (percentage or score) * Document method as manual or computer-assisted
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Flow Markers | * Indicate if both technical component and professional components should be billed, or if the pathologist only does the interpretation (professional component only) * Result of each marker should be clear for appropriate counting/charge capture
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APS will continue to provide feedback on coding or documentation issues found commonly amongst our client base.
