CPT Code 85025: Guidelines, Considerations, and Requirements

Are you getting mixed up with the services associated with the CPT code 85025? We’re here to clear all your doubts with a detailed blog on this code. We look at some key guidelines that can help you assign it accurately.

There are some billing considerations mentioned as well with which you can seamlessly code your medical services. In the end, we discussed a lot of documentation requirements that you must fulfill while assigning this code. Contact Health Quest Billing to get your services accurately coded.

What Is CPT Code 85025?

The CPT code 85025 comes under the Hematology and Coagulation Procedures range. It is assigned to a complete blood count test. This test is usually requested by healthcare providers. It provides additional details about the different cells in a patient’s blood.

This test is conducted by a technician or pathologist who then hands over the results to the requesting doctor. They draw blood from a vein using a syringe. The blood is stored in a test tube that contains an anticoagulant.

The full form of CPT in medical coding is Current Procedural Terminology. This name is associated with specific numeric codes that are assigned to medical services. Healthcare providers and insurance companies use CPT codes to identify those services while billing them.

As a medical billing company specializing in Hematology billing, we understand the importance of accurate CPT code assignment for Hematology Coagulation Procedures.

Key Guidelines for Assigning CPT Code 85025

There are some key guidelines that you must follow while assigning the CPT code 85025. Let’s take a look at them in detail:

• Comprehensive Blood Count

You can only assign 85025 if all the essential components of the CBC test are conducted. They provide a detailed analysis of a patient’s blood. The red blood cell count measures the number of red blood cells.

The white blood cell count determines the number of white blood cells. Hemoglobin evaluates the hemoglobin level in the blood. Hematocrit measures a specific proportion of red blood cells. It helps diagnose dehydration, anemia, and other conditions.

Whereas, platelet count assesses the number of platelets in the blood. All these components must be included in the CBC test for it to be billed under 85025.

• No Additional Tests

CPT Code 85025 is only appropriate for a standard CBC test. Some additional tests may also be performed beyond CBC. Some examples of such tests are differential white blood cell count and reticulocyte count. In this case, they should be billed separately using their relevant CPT codes.

An example can be assigning 85027 instead if a differential is manually counted. Your procedures should match the medical services associated with the CPT Code 85025. Over-coding or under-coding can lead to denied claims or legal issues.

• Single Report

Healthcare providers must document the result of their CBC test in a single report. It is possible that the components of a test are spread across multiple reports. In this case, it may not be appropriate to assign the CPT Code 85025.

Multiple reports could imply that separate medical services were performed. Such services may require different codes. A single detailed report clarifies that all components of a CBC test are performed. This is done in a single patient encounter to prevent documentation errors.

• Reimbursement for Repeat Tests

There are specific guidelines set for repeating CBC tests as well. It is possible that a CBC test is repeated within a short period. A short period is usually considered within 24 hours or even the same day. In this case, insurance companies may not reimburse for the second test.

They can only reimburse it if there is a clinically justified reason. The reimbursements of CBC tests are largely based on their medical necessity. Therefore, you must always document why the repeat CBC is needed.

Billing Considerations for CPT Code 85025

You must also be aware of certain considerations while billing claims associated with the CPT code 85025. Here is a detailed explanation of the primary ones:

• Correct Billing Entity

The CPT Code 85025 should be billed by the entity that actually performs the CBC test. This is typically the hospital where the blood sample is drawn and analyzed. A third party, who did not perform the actual test, should not assign this code.

• Bundling

The CPT Code 85025 may be subject to bundling rules. Bundling refers to the inclusion of multiple services under a single payment code. This can occur if a CBC is performed as part of a more comprehensive panel of tests.

In some cases, this code is bundled with another medical service or package. This practice can affect the reimbursement rate. Consider an example of a CBC test conducted as a part of a comprehensive metabolic panel. The insurance company may reimburse only for the panel.

It may not cover its individual components separately. You should always check payer-specific bundling edits. This way, you can understand how CBC tests are grouped with other services.

• Payer Policies

Insurance companies have different policies for reimbursing the code 85025. Some of them may have limitations on frequency. Others may require pre-authorizations or specify limited scenarios for approved claims. Regularly review and stay up-to-date with the policies of each payer.

• Medical Necessity

One of the main billing considerations is justifying the medical necessity of CBC tests. You must prove that they are necessary based on your patient’s health factors. Those factors primarily include their symptoms, medical history, and ongoing treatment.

You must document the medical necessity in the patient’s record. The reason for the CBC test should always be stated. Common reasons comprise the diagnosis of anemia and infection. Keep in mind that insufficient documentation can cause claim denials.

• Modifiers

Modifiers are codes added to CPT codes to provide additional context. They provide extra details about the services performed. The CPT code 85025 may also require modifiers in certain patient cases. Here are two modifiers that are usually appended to it:

• Modifier 59: This modifier is used if the CBC is performed separately from other services. Those services are typically bundled together.
• Modifier 91: You can assign this modifier if you have repeated the CBC test on the same day for valid medical reasons.

Documentation Requirements for CPT Code 85025

Healthcare providers must also fulfill certain requirements in terms of their documentation. We have listed some of those requirements below:

• Medical History

The patient’s medical history must be documented. It provides context for why a CBC test was ordered. This includes recording any relevant symptoms or underlying conditions that necessitated the test.

Documentation should also include any past medical events or diagnoses. They could justify the need for a CBC test. This comprehensive medical background helps establish the medical necessity for the test. It is also crucial for the reimbursements from insurers.

• Clinical Indications

The specific clinical indications for ordering the CBC should be clearly stated. This could include routine check-ups or preoperative evaluations. There are some conditions as well like anemia, polycythemia, or other hematological issues. Some patients undergo treatments for conditions that can affect blood cell counts.

You may also have to monitor a known infection or identify inflammatory diseases. The documentation should clearly articulate why the CBC was necessary at the time of the order. Those details can support its medical necessity for billing purposes.

• Test Order

The documentation must include the date and time the CBC test was ordered. The order should specify whenever a CBC with automated differential WBC Count was needed. This prevents ambiguity and ensures that the appropriate test was requested.

• Specimen Collection

It is essential to document the date, time, and type of specimen collected. For a CBC, this typically involves a venous blood sample. Proper documentation of specimen collection is critical. It demonstrates the integrity of the sample.

It also explains its direct relation to the specific patient and test order. This information also validates that the procedure was carried out appropriately.

• Test Results

The results of the CBC must be clearly documented. Those documents should include the date the results were received. Specific values for each component of the test need to be noted. Accurate and detailed reporting of these values is essential. A test can include an automated differential WBC count. In this case, those results must also be recorded.

• Treatment Plan

The CBC results can lead to changes in the patient’s treatment plan. In this case, these changes should be specifically documented. An example can be medication adjustments. These adjustments are made to the dosage or type of medication based on blood counts.

Another example can be further diagnostic testing. You can recommend additional tests based on abnormal CBC results. In addition, you can refer your patients to a specialist. You can also schedule follow-up appointments for them to monitor changes.

There should be clear justifications provided for such changes. The reason behind any modification to the treatment plan based on the CBC results should be clearly explained. This directly supports the medical necessity and relevance of those tests.

• Clinical Interpretation

The documentation should include the interpretation of the relevant physician. They should interpret the CBC results in the context of the patient’s clinical condition. This interpretation may discuss how the results support or refute a potential diagnosis.

It may also reveal how they relate to the patient’s existing medical conditions. The interpretation should directly tie the results to the patient’s symptoms, conditions, or treatment plan. This way, they can provide a clear link between the CBC results and patient management.

The Bottom Line

This blog explored how the CPT code 85025 can be accurately assigned. We looked at the key guidelines that you should follow while assigning it. There were some vital billing considerations mentioned as well related to it.

In the end, we discussed a wide range of documentation requirements that have to be fulfilled while assigning 85025. Contact Health Quest Billing to ensure you don’t miss out on any effective coding policy.