How to use the CPT codes for CBC
CBC CPT Codes (complete blood count) can be billed with CPT 85025, CPT 85027 and CPT 85007. The 85025 CPT code can be billed for complete blood count with automated differential. The 85027 CPT code and the 85007 CPT code can be billed for CBC with manual differential.
CPT Code 85025 For CBC With (Automated) Differential
The first CBC CPT Code is 85025 and comprises a white blood cell differential, or “diff,” in which these leukocytes are differentiated. It can be billed when a CBC is performed with automated differential WBC count and is described as:
85025 CPT Code Description & Billing Guidelines
CBC complete, automated (WBC, , RBC, Hct, , Hgb, and platelet count) and WBC differential.
The usage of CPT 85025 is supported by laboratory test results that demonstrate automated CBC as well as differential WBC (As long as the doctor prescribed them).
For example: The lab gets a request for a CBC. They perform a CBC with an automated differential and charge for CPT 85025. Will this withstand an audit?
No, it does not. Reporting CPT 85025 would be deemed as incorrect unless the order clearly says that a differential is desired. In this case, the appropriate code to report is CPT 85027. The incidence of incorrect billing caused by the abuse of CPT 85025, as depicted in this case, is estimated by Medicare‘s Comprehensive Error Rate Testing to be as high as 30%. (CERT)
CPT Code 85027 & 85007 For CBC With Manual Differential
CPT code 85027 (automated hemogram) the 85007 CPT code (manual differential WBC count) may be submitted if a treating clinician requests the same. The descriptions of these CBC CPT codes are as follows:
85027 CPT Code Description
Complete CBC, automated. Hct, Hgb ,WBC, RBC and platelet count.
85007 CPT Code Description
CPT 85007 can be billed for CBC blood test with manual differential and is defined as: Blood count. Blood smear. Microscopic examination with manual differential WBC count.
The sample is whole blood. Manual testing is the method utilized. A blood smear is created and inspected under a microscope for the detection of normal cell components such as white blood cells, red blood cells, and platelets.
A manual differential of white blood cells is contained in CPT 85007, which differentiates the various leukocytes;
- neutrophils or granulocytes;
- lymphocytes;
- monocytes;
- eosinophils; and
- basophils.
85007 CPT Code Reimbursement
A provider may not submit an automated hemogram with automated differential WBC count (85025 CPT code) together with a manual differential WBC count (85007 CPT code) since doing so results in double reimbursement for the differential WBC count. The CMS will not pay for the same medical test result twice, even if it is conducted by two separate procedures, unless the two methods are medically acceptable and essential.
CPT 85025 And CPT 85027 Reimbursement & Billing Guidelines
The lab tests must be ordered for the CBC CPT codes by the doctor or NPP who treats a patient for a particular medical concern and utilises test results to manage the patient’s medical situation to avoid denials for the 85025 CPT code and the 85027 code. Tests that are not ordered in order to treat the patient are not reasonable or essential. Documents demonstrating medical necessity for treatments ordered should be kept in the patient ‘s medical file.
The organisation providing the claim must retain documentation from you demonstrating accurate order processing, claim submission, and diagnostic or other medical data you provided to the lab, such as any ICD 10 code or descriptive explanation.
Documentation
The following orders of the diagnostic lab include the following in order to get reimbursed for CPT 85025 and CPT 85027:
- a written order or a signed requisition detailing the particular test;
- Unsigned order or unsigned lab request detailing particular tests performed, as well as an authorised medical record supporting the desire to order the tests (for example, order labs, check blood, or repeat urine)
- A medical document that has been authenticated to support your decision to order particular testing.
Limitations
Screening entails testing for persons who are asymptomatic or do not have an illness that might cause a haematological anomaly, hence it is not a covered procedure. In limited occasions, simply a haemoglobin or hematocrit test may be necessary to determine the oxygen carrying capacity of the blood. The remaining components of the CBC are not covered when the ordering provider requires simply a haemoglobin or hematocrit.
When a blood count is conducted for an ESRD patient and charged at a rate other than the ESRD rate, documentation of the blood count’s medical necessity must be presented with the claim.
A single CBC may be useful in some individuals who arrive with specific signs, symptoms, or illnesses. Repeat testing may be unnecessary unless aberrant results are discovered or there is a change in clinical condition. If additional testing is conducted, a more descriptive diagnostic code should be supplied to demonstrate medical need. Repeat testing, however, may be needed when findings are normal in patients with diseases that provide a continuing risk of hematologic abnormality development.
Modifiers
When repeated results are required throughout management, modifier 59 or modifier 91 are used to indicate that a test was done more than once on the same day for the same patient and can be coded along the CBC CPT codes.
Modifier 91 (repeat clinical diagnostic laboratory test) is used to indicate when further lab tests are performed on the same patient on the same day. Billing this modifier can help with the reporting of additional medically necessary CBC component test(s) for the CBC CPT codes. The 91 modifier is utilised for CBC CPT codes tests covered by the clinical laboratory fee schedule. These modifiers may be used to indicate that a test was conducted more than once on the same day for the same patient, but only when numerous results are required throughout therapy.
These modifiers should not be used when CBC tests are redone to confirm original findings due to specimen and equipment issues, or for any other cause where a normal, one-time, reportable result is all that is required.
When there are established HCPCS codes that explain the series of the CBC tests (for example glucose tolerance tests or evocative/suppression testing), these modifiers may not be utilised. These modifiers can only be used for laboratory tests covered by the clinical laboratory fee schedule.
CLIA Waived Test
The 85025 CPT codeis a CLIA waived test. The purpose of the CLIA programme is to ensure high-quality lab tests. Modifier QW is a waived Clinical Laboratory Improvement Amendment (CLIA) test. Those tests needing the QW modifier are considered simplified analysis tests. To lawfully perform clinical laboratory testing, CLIA requires all laboratory testing locations to acquire one of the following certificates:
- Certificate of registration;
- Certificate of accreditation;
- Certificate of waiver; and
- Certificate for physician-performed microscopy.
Reimbursement Fees
| Modifier | Reimbursement | |
| 85025 CPT Code | No | $7.77 |
| 85025 CPT Code | QW | $7.77 |
| 85027 CPT Code | No | $6.47 |
Medically Unlikely Edits
| Practitioner Services | Outpatient Hospital Services | |
| 85025 CPT Code | 2 | 4 |
| 85027 CPT Code | 2 | 4 |
