Rising above the complex laboratory billing requirements and ensuring accurate reimbursements can be a significant challenge. Even services like complete blood count (CBC) come with intricate coding and billing guidelines. Non-compliance with these can lead to denials and revenue leakage.
Therefore, mastering bundling rules, understanding medical necessity, and appending appropriate modifiers are integral. This guide will help you master CPT code 85025. Thus, we recommend that you read it till the end. It will help you capture every dollar that you rightfully deserve for these diagnostic services.
So, without further ado, let’s get started!
CPT Code 85025 – Description
CPT code 85025 covers a complete blood count, most commonly referred to as CBC with automated differential counting of white blood cells (WBC). It is a blood test that offers detailed insight into various cell types in the patient’s blood sample.
How does it work? Blood is drawn from the patient using a syringe and stored in a test tube containing an anticoagulant. Typically, they use EDTA or citrate to prevent clotting. The collected specimen is sent to a lab for analysis. A technician or a pathologist performs the test using an instrument known as an “automated analyzer”.
For the unversed, an automated analyzer counts the number of various blood cells. Finally, a printed form of the findings is ready for review by the ordering healthcare provider.
Scenarios Where CPT Code 85025 is Applicable
If, even after reading CPT code 85025’s descriptor, you still lack clarity on where this code applies, the following clinical scenarios will help you gain a better understanding:
Suspected Anemia Investigation
Did you know? The overall prevalence of anemia among individuals aged two or older was 9.3% during the period 2021-2023.
Picture a 40-year-old female patient who visits her primary care physician. She complains of occasional dizziness, generalized weakness, and persistent fatigue over the past few months. Moreover, she reports feeling unusually cold.
The physician suspects anemia and orders a CBC to evaluate red blood cell count, hematocrit, hemoglobin, and other indices. The test also involves white blood cell and platelet counts to determine the reason behind the patient’s symptoms.
Here, CPT code 85025 applies.
Acute Infection Evaluation
Assume a 5-year-old girl with a high fever (102.7 °F), lethargy, and sore throat for the past two days. Her parents took her to the pediatrician, who observed swollen lymph nodes and inflamed tonsils.
Thus, the pediatrician orders a CBC (with differential) to determine whether the infection is bacterial or viral. It will also help the physician assess the child’s immune system by revealing white blood cell count and their various components, including lymphocytes and neutrophils.
Hence, CPT code 85025 will be reported to bill for CBC with differential.
Chemotherapy Side Effects Monitoring
Imagine a 58-year-old female patient who has been receiving chemotherapy for breast cancer. She has a scheduled follow-up visit with the oncologist. As per the physician’s orders, a CBC with automated differential (CPT code 85025) is required before each chemotherapy cycle to monitor the bone marrow function of the patient.
Moreover, this laboratory test assesses for myelosuppression (decreased blood cell production), helping oncologists determine whether it is safe to proceed with the next treatment dose.
For context, cancer treatment may lead to serious complications, including low blood cell count.
Applicable Modifiers for CPT Code 85025
Here’s a list of some applicable modifiers to ensure coding specificity and fair reimbursement:
Modifier 59
Append modifier 59 to CPT code 85025 when another significant and separately identifiable laboratory service is performed for the same patient on the same day as CBC with automated differential. How does it help? This modifier prevents payment cuts or denials due to bundling of services that are otherwise performed together.
Modifier 90
What happens when a reference laboratory performs the CBC with automated differential? The reference laboratory should report CPT code 85025 with modifier 90 to ensure accurate reimbursement and prevent denials.
But what is a reference laboratory, and under what circumstances can it bill services with modifier 90? Sometimes, one laboratory sends the specimen to another lab for additional testing or because it does not have the required resources. The second lab is called the reference lab.
Modifier 91
There may be scenarios where a patient’s condition demands subsequent results. As a result, the same qualified healthcare professional (QHP) or group practice physician repeats the CBC on the same day.
When this happens, you must append modifier 91 to CPT code 85025. It highlights that the repetition was clinically necessary and prevents denial due to duplication.
CPT Code 85025 – Billing & Reimbursement Guidelines
Don’t want to leave money on the table while billing for CBC tests? This section will help you understand how you can properly bill for CPT code 85025 for accurate charge capture:
Understand the Bundling Rules
Remember that the reimbursement for CPT code 85025 typically bundles with the general health panel test, represented by CPT code 80050. This code covers all three tests: thyroid function test, metabolic panel, and CBC.
Therefore, if the laboratory renders these services simultaneously, payers emphasize billing them under a bundled code rather than individually. Non-compliance with these bundling rules can result in denials or audits.
Demonstrate Medical Necessity
Ask the million-dollar question before submitting the claim reporting CPT code 85025: Was the CBC medically necessary? Why is it so critical to determine? Because reimbursement hinges upon supporting medical necessity.
Therefore, your medical claim must include the clinical indication and the relevant ICD-10-CM codes, which identify the patient’s symptoms and conditions. Some of the most common indications include:
- Sepsis, unspecified organism (A41.9)
- Iron deficiency anaemia, unspecified (D50.9)
- Pneumonia, unspecified organism (J18.9)
Ensure Detailed Documentation
Another essential reimbursement guideline for CPT code 85025 is ensuring complete and accurate patient records. Therefore, your documentation must include the following:
- Mention the clinical indication, including symptoms, signs, and diagnosis.
- Include the physician’s order for performing a CBC with automated differential.
- Utilize a relevant ICD-10 code to establish medical necessity for performing the test.
- Attach the test report.
Summary
We can finally call it a wrap, but don’t you want to review the key takeaways of this comprehensive guide before saying adieu?
First, we explained the CPT code 85025 descriptor. It covers automated CBC with automated differential. Next, we shared some clinical scenarios where this CPT code applies. These include suspected anemia investigation, acute infection evaluation, and chemotherapy side effects monitoring.
We also shared a list of all applicable modifiers, including 59, 90, and 91. Finally, we discussed the essential billing and reimbursement guidelines related to CPT 85025.
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