Pathology/Lab Coding Alert
Stay on Top of April Updates for Path/Lab MUEs, Fees, and ICD-10-CM
Plus, see what鈥檚 in store for PLA changes in July. The second quarter of 2025 is now here, so it鈥檚 time to make sure your knowledge is up to date for the coding data changes aimed at path/lab coders. And it鈥檚 also not a bad idea to get a sneak peak of what is coming down the road for the remainder of the year. Know Why MAI Changes Matter for MUEs Each quarter, Medicare updates the Medically Unlikely Edits (MUEs) that it applies to codes. As explains, 鈥淎n MUE is the maximum units of service (UOS) reported for a HCPCS/CPT庐 code on the vast majority of appropriately reported claims by the same provider/supplier for the same beneficiary on the same date of service.鈥� In short, if you report units that exceed a code鈥檚 MUE, you鈥檙e typically going to trigger a denial. But to understand MUEs, you also need to understand the MUE Adjudication Indicator (MAI) that Medicare publishes along with each MUE. For path/lab codes, you can expect to see MAI 2 or 3. These both signify that the MUE is a date of service (DOS) edit rather than a claim line edit. That means Medicare checks how many units of a code you report for a patient on a single date rather than checking the units for only a single line item. MUE MAI 2: MAI 2 indicates an absolute DOS edit based on policy. In other words, Medicare hasn鈥檛 identified any instances where exceeding an MUE with MAI 2 is correct. So, if you report units that exceed the code鈥檚 MUE on a single DOS, expect a denial. MUE MAI 3: If the MUE has MAI 3, you again can expect a denial when you exceed a code鈥檚 MUE for a single DOS. But MAI 3 is based on clinical benchmarks, so Medicare may pay extra units if you appeal, or Medicare may bypass the MUE based on documentation of medical necessity. Keeping all of that in mind will help you understand the significance of three revisions to Proprietary Laboratory Analyses (PLA) codes, effective April 1. These codes all shifted from MAI 3 (potential for appeal or bypass) to MAI 2 (absolute edit). But it isn鈥檛 surprising that Medicare considers these to be codes you鈥檇 report only once for a DOS: Codes 0047U and 0069U have an MUE of 1 in both the first and second quarters. But 0313U had an MUE of 2 in the first quarter and an MUE of 1 in the second quarter. Another code also changed from an MUE of 2 to an MUE of 1: 0211U (Oncology (pan-tumor), DNA and RNA by next-generation sequencing, utilizing formalin-fixed paraffin-embedded tissue, interpretative report for single nucleotide variants, copy number alterations, tumor mutational burden, and microsatellite instability, with therapy association). For 0211U, the MAI remains 3. Additions: The April MUE update adds MUEs of 1 for PLA codes 0476U to 0520U. Those codes were effective Oct. 1, 2024. Medicare also added MUEs for the new 2025 Category I path/lab codes (the codes that were effective Jan. 1, 2025). These codes have MUEs of 1 as well. Consider These New Codes Contractor-Priced;/ 惭别诲颈肠补谤别鈥檚 (CLFS or CLAB) added several codes in April, but they are all contractor-priced for now. That means contractors determine the pricing. The additions include PLA codes effective April 1 (0531U to 0551U) and also HCPCS Level II code G0567 (Infectious agent detection by nucleic acid (dna or rna); hepatitis c, screening, amplified probe technique), which was released just recently but has an effective date going back to June 27, 2024. Watch for Index Changes in ICD-10-CM In recent years, ICD-10-CM has switched from making updates annually on October 1 to also making updates on April 1. This year, the did not include new codes, but you should be sure you鈥檙e using the latest release because instructional notes and index entries have changed in this update. Examples: Watch for whether ordering providers are aware that ICD-10-CM now indexes Decrease/glucose to E16.2 (Hypoglycemia, unspecified) instead of R73.09 (Other abnormal glucose). The index entry for Infection/Cronobacter (sakazakii) has also changed, replacing B96.89 (Other specified bacterial agents as the cause of diseases classified elsewhere) with A49.8 (Other bacterial infections of unspecified site). Prepare for July PLA Changes The AMA also posts quarterly updates that are important for lab coders, with the PLA code changes going into effect in the quarter following their release. On April 1, AMA posted changes for PLA codes going into effect July 1. Additions: The July update will bring 23 additions, listed as 0552U-0574U. The tests cover reproductive medicine, infectious disease, oncology, rare diseases, and neurology 鈥� specifically dementia and traumatic brain injury. Revision: Expect an update to the descriptor for RadTox鈩� cfDNA test code 0285U. The revision broadens what the test checks for and changes how the result is reported: Deletions: The July update deletes six codes: Name changes: If you report melanoma code 0089U, breast cancer code 0220U, neurology (Parkinson鈥檚, dementia) code 0393U, or urothelial oncology code 0420U, to their proprietary, clinical laboratory, and manufacturer names. For instance, 0089U changes from Pigmented Lesion Assay (PLA) to Pigmented Lesion Assay (DermTech Melanoma Test). These changes are important because each PLA code describes a unique lab test made by a specific manufacturer or performed by a specific lab. Deborah Marsh, JD, MA, CPC, CHONC, Senior Development Editor, AAPC
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