A recent analysis of Medicare contractors’ Comprehensive Error Rate Testing (CERT) Web sites showed an increase in errors due to incorrect coding for CBCs. Because the CBC is one of the most frequently ordered tests, the high volume of claims makes it an easy target for scrutiny.

What do the CERT audits show?

A CBC is a hematology test typically ordered by physicians to diagnose and treat a wide array of physical disorders. The test involves measuring a blood specimen for levels of hemoglobin, hematocrit, red blood cells, white blood cells and platelets. Also included is a differential white blood cell (WBC) count that measures the percentages of different types of white blood cells. The correct CPT code for this test is:

85025: Complete Blood Count, with differential WBC, automated.

Many providers order a CBC, but do not specify that they want the automated WBC differential count. If this is the case, the correct CPT code for this test is:

85027: Complete Blood Count, automated.

CERT record audits show that providers are billing CPT 85025 when documentation only supports the reporting of CPT 85027. CERT reviewers are seeing continuing error rates in the 30 percent range.

What’s The Impact?

It sounds like a broken record, but when it comes to CERT, RACs, focused medical review or any other Medicare-type audit, just follow the money. Providers that bill unsupported codes will be overpaid. The Medicare Lab Fee Schedule shows the following current payment rates:

85025………………. $11.14

85027………………..   $9.27

A $2 differential does not sound like much, but the volume of CBCs performed on a yearly basis is very large, and small dollar amounts multiplied by large volumes can add up very quickly. Besides the risk of overpayments, consider the other intangible and direct costs of incorrect coding such as:


  • Dealing with a medical review probe
  • Administrative cost of photocopying, record retrieval, etc.
  • Filing appeals
  • Making claim adjustments

What Should You Do?

1)   Start with the Order

A physician’s signature is not required on orders for clinical diagnostic tests (including X-ray, laboratory and others) that are paid on the basis of a clinical laboratory fee schedule, the Medicare Physician Fee Schedule or for physician pathology services. While a physician order is not required to be signed, the physician must document clearly in the medical record his intent that the test be performed. Remind your ordering physicians of the following:

  • Tests must be ordered by the physician treating the beneficiary.
  • The physician must document clearly in the medical record intent to have the test performed.
  • Intent to order a CBC, with or without a WBC differential, must be stated clearly.

2) Code the Service Correctly

To prevent denials, providers should review medical records and physician orders/requisitions before performing and coding services to make sure that what is being ordered, performed and billed all match.

  • If the physician has ordered only a CBC, with no mention of a differential, the correct code is 85027.
  • If the physician has ordered a CBC with a WBC differential, plus laboratory test results that show automated CBC as well as the differential WBC support, the correct code is 85025.
  • Another common error is billing of CBC CPT code 85025 when only hematocrit and hemoglobin laboratory tests have been completed.Providers are advised to make sure they are completing the tests ordered by the physician and only bill for tests actually completed on the bill.

3) Monitor Compliance.

The impact of noncompliance includes denial of payment, focused reviews and/or audit referrals. Make sure that your efforts pay dividends in the long run by conducting periodic spot reviews of CBC documentation, coding and billing patterns.
Focus your efforts on the following limitations as described by the National Coverage Decision Policy for Blood Counts 190.1, found in Medicare Publication Number 100-3:

1.   Testing of patients who are asymptomatic, or who do not have a condition that could be expected to result in a hematological abnormality, is screening and is not a covered service.

2.   In some circumstances it may be appropriate to perform only a hemoglobin or hematocrit to assess the oxygen carrying capacity of the blood. When the ordering provider requests only a hemoglobin or hematocrit, the remaining components of the CBC are not covered.

3.   When a blood count is performed for an end-stage renal disease (ESRD) patient, and is billed outside the ESRD rate, documentation of the medical necessity for the blood count must be submitted with the claim.

4.   In some patients presenting with certain signs, symptoms or diseases, a single CBC may be appropriate. Repeat testing may not be indicated unless abnormal results are found, or unless there is a change in clinical condition. If repeat testing is performed, a more descriptive diagnosis code (e.g., anemia) should be reported to support medical necessity. However, repeat testing may be indicated where results are normal in patients with conditions where there is a continued risk for the development of hematologic abnormality.


About the Author


Randy Wiitala, BS, MT (ASCP) conducts CPT coding and chargemaster assessments, reviews provider operations for regulatory agency compliance, evaluates administrative policies and procedures and assists in the development of quality-assurance programs. He’s also a frequent seminar presenter, speaking to hospitals, corporations, clinics, state hospital associations and professional organizations. These educational programs cover a variety of areas, such as coding, regulatory compliance and reimbursement for laboratories; chargemaster system management; and APCs. Randy contributes to a number of MedLearn books, as well as the Laboratory Compliance Manager newsletter. He is the project lead on MedLearn’s RAC Outpatient Data Analytics. He is a member of the American Society of Clinical Pathologists, the National Certification Agency and Healthcare Financial Management.


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