The CPT code A Complete Blood Count (CBC) has no specific ICD-10 codes and must be accompanied by diagnosis codes to support medical necessity. CBC testing must be linked to diagnosis codes, payer policy coverage documentation, and ICD-10 coding to justify, support, and defend against payer claim denials. Strong documentation, good coder/provider communication, and routine audits allow compliant billing to facilitate cash flow.
A Complete Blood Count (CBC) testing is the most commonly ordered lab test in every healthcare setting. CBC testing is used to assess infections, anemia, inflammatory processes, abnormalities in the blood, and overall patient health. CBC tests are used in almost every case, and CBC-related claim denials are frequent. Improper coding of the diagnosis is the cause. CBC tests are seen as having their own diagnosis code. Providers and coders do not understand that the ICD-10 codes are for medical conditions and symptoms, and not lab tests. Assigning the ICD-10 code of the diagnosis that justifies testing is one of the most important factors in establishing medical necessity, and also compliance with the payer to get the claim paid.
CBC Test
A Complete Blood Count (CBC) assesses several components of blood, including red blood cells, white blood cells, and platelets (as well as hemoglobin and hematocrit levels). Clinicians use CBC results to evaluate possible infections, monitor chronic illnesses, evaluate risk of bleeding, and even assess the nutritional status of patients. From a billing standpoint, CBC tests are identified by CPT codes (Current Procedure Terminology codes) like 85025 or 85027. The further provided CPT codes, however, will only receive reimbursement if the associated ICD-10 (International Classification of Diseases, 10th Edition) diagnosis code justifies clinically the reason for testing. CBC tests are often considered by a payer to be routine or unnecessary if diagnosis code(s) in support of the test order are not provided.
Is There a CBC ICD-10 Code?
There are no ICD-10 codes for CBC’s (Complete Blood Count Tests). ICD-10 coding presumes a disease, symptom, or abnormal clinical finding. They do not account for procedures or laboratory testing. A CBC must be associated with an ICD-10 code that describes the patient’s condition or symptoms under assessment/evaluation. From an ICD-10 coding perspective, it is inappropriate, and a frequent cause for the rejection or denial of a claim, to use procedural or laboratory terminology.
Typical ICD-10 Codes Supportive of CBC Testing
CBC testing is often accompanied by ICD-10 codes based on symptoms when a definitive diagnosis has not been determined. Codes for fatigue (R53.83), fever (R50.9), weakness (R53.1), or unexplained weight loss (R63.4) may justify testing. When a diagnosis is known, codes for anemia (D64.9), iron deficiency anemia (D50.9), leukocytosis (D72.829), thrombocytopenia (D69.6), or infections are more suitable. The selected diagnosis code should be reflective of what the provider noted prior to the CBC order, not post-test conclusions.
The Relationship of CBC Tests to Medical Necessity
Payers determining CBC claims are most concerned with the medical necessity and clinical justification for the CBC, as demonstrated by the diagnosis code. A CBC may be justifiable for a patient with unexplained fatigue, dizziness, and pallor to rule out anemia. If supporting symptoms and conditions are not documented in the medical record, the payer is likely to rule the claim is not medically necessary. The diagnosis code should reflect the provider’s documented assessment within the medical record.
Differences in Coding Between Screening and Diagnostic CBC Tests
For correct coding and reimbursement, it is important to differentiate screening and diagnostic CBC testing. Screening CBCs do not have any symptoms and these CBCs are part of normal physical check ups. In fact, these CBCs do not get coverage from Medicare or many commercial payers, unless specifically noted in preventive care benefits. Diagnostic CBCs are tests done with the purpose of evaluating certain symptoms or managing existing connditions. Coding diagnostic CBCs with the correct symptom or condition ICD-10 code will help establish medical necessity and ICD-10 code augmentation.
Coverage Rules Impacting Medicare and Other Payers
Medicare along with numerous private payers issue coverage policies, specifically Local Coverage Determinations (LCDs) which document which ICD-10 codes related to medical necessity for CBC testing. These policies also state frequency and clinical limitations. If the tests are appropriate, the diagnosis codes will be outside the contracted clinical guidelines and will lead to denial of the claim. That is why reporting according to the diagnosis code is vital in compliance for billing.
Requirements for Documentation for Coding of CBC
The provider’s documentation is critical to diagnose coding accurately. Important aspects the medical record needs to contain are the patient’s symptoms, clinical findings, or medical history that justify the CBC order. Coders can’t make assumptions for a diagnosis based on lab findings. An example is a low hemoglobin value. Unless the provider states the diagnosis, coding for anemia can’t be done. Unclear documentation increases the potential for audits and denials, while clear and thorough documentation reduces the potential. It also justifies the selection of a particular ICD-10 code.
Coding mistakes leading to claim denials
The provider’s documentation is critical to diagnose coding accurately. Important aspects the medical record needs to contain are the patient’s symptoms, clinical findings, or medical history that justify the CBC order. Coders can’t make assumptions for a diagnosis based on lab findings. An example is a low hemoglobin value. Unless the provider states the diagnosis, coding for anemia can’t be done. Unclear documentation increases the potential for audits and denials, while clear and thorough documentation reduces the potential. It also justifies the selection of a particular ICD-10 code.
Diagnosis Coding that is Not Specific
The use of unspecified ICD-10 codes is one of the greatest coding mistakes that is subject to claim denials most frequently. In some circumstances, it’s okay to use a code that is deemed unspecified but most of the time a payer is not going to accept the claim if they have reason to believe specificity was not provided. It can be helpful to improve the specificity of coding to avoid rejection of a claim.
Diagnosis of a Disorder and Laboratory Findings
Another of the more common errors is the coding of diagnoses based on the abnormal findings of a CBC and not the documented diagnosis from the provider. Such is the case of translating the lab results into a diagnosis. Coders should not be documented in a laboratory. This usually results in claims being rejected, compliance problems, and inaccurate medical records.
Considering Prevention Codes Incorrectly
Considering prevention or screening diagnosis codes while working on diagnostic CBC testing typically results in non-covered services. Using screening codes may demonstrate a lack of medical necessity to justify the order, and may lead to CBC order denials.
Documentation and Coder Discrepancies
The claim may also be denied due to a mismatch of the diagnosis code submitted to the provider’s documentation. Discrepancies between the documentation and the claim are the most concerning issues during an external review of the claims.
Documentation and Coder Discrepancies
Support Clinical Justification
All CBC orders without a Clinical Justification will remain in the billing system indefinitely, and the die will be cast for a waiting game unless and until the clinical condition warrants further exploration through the CBC order. Coders must be able to understand the basis for medical necessity in order to justify the order.
Use the Most Specific ICD-10 Code
Using the most specific code available is a means of improving the accuracy and compliance of the claim. Specific diagnosis codes improve the quality of the bundled Claim Data Set and reduce queries related to the claims.
Understand the Clinical Justification for the CBC
The CPC should contain a defined clinical justification for the CBC. This will likely lead to the claim not being denied, and the ICD claims to reflect acceptable criteria for a clinical justification. Coders, and any clinical staff, need to be familiar with the clinical justification for the CBC in order for the claim not to be denied.
Better Communication Between Providers and Coders
It is easier to clarify gaps in documentation and ensure the provider’s diagnosis is captured in the claim when there is good communication between provider and coding staff. They can teach providers the documentation needed in order to lower denials related to coding.
Routine Audits and Analysis of Denials
One of the most significant ways to resolve recurring issues is to perform internal audits and review CBC claims for denials. When organizations address those recurring issues before audits, it improves the accuracy of billing and positively impacts revenue.
Impact of Diagnosis Coding for Value-Based Care
In value-based care models, diagnosis coding for CBC (Complete Blood Count) is critical. Diagnosis codes determine the quality of care metrics, risk adjustment, population health reporting, and care coordination. If coding is inaccurate, it compromises the integrity of the patient data and negatively impacts reimbursement. Coding accurately ensures CBC testing data is useful for clinical decision making, and healthcare analytics.
Conclusion
The claim for CBC (Complete Blood Count) Testing can get denied due to improperly documented diagnosis codes. The ICD-10 codes, reflect the provider’s diagnosis, reasons, or symptoms, and should support the CBC testing. Healthcare organizations that know the rules for the payers, refrain from coding errors, and implement best practices can reduce denials while providing quality care to patients.
Make An Appintment With A2ZFAQs
There are no ICD-10 codes that apply to CBC. CBC codes are procedural codes that describe the lab test ordered by the physician, and ICD-10 codes are issued for reasons explaining the medical diagnosis, symptoms or conditions that involve the CBC.
Common codes are ICD-10 codes that are based on symptoms like fatigue (R53.83), fever (R50.9), and weakness (R53.1) as well as condition based codes like anemia (D64.9), or thrombocytopenia (D69.6) etc. Documentation is everything.
CBC claims are denied most often by the medical necessity, nonsensical use of screening or preventive codes used for diagnostic testing, vague/deliberately unspecified diagnosis codes, and inadequate provider documentation.
Only the CBC abnormal results are not from the diagnosis, and can only be coded as abnormal results if the provider documents the clinical record with regard to an associated or corresponding medical condition.
Health care organizations can reduce claims denials by documenting with clarity, being specific with the ICD-10 codes selected, being aware of the constructs of coverage verification of the payer, keeping the provider comments open with the coder, and by conducting the audits that are frequent.