CBC – Blood Counts: Local Medical Review Policy


Blood counts are used to evaluate diseases such as anemia, leukemia, reaction to inflammation and infections, polycythemia, hemolytic disease of the newborn, and to monitor treatment effects with some high risk drugs, etc. The complete blood count (CBC), commonly includes WBC, Hct, Hgb, platelet count, RBC count, RDW count, WBC and RBC morphology, WBC differential count, and histograms. Histograms are helpful, especially, to the technologist in detecting problems with quality control, as well as patients.

A complete blood count is generally performed with automated equipment. In addition to the above, the CBC frequently provides calculated results such as, mean corpuscular volume (MCV), mean corpuscular hemoglobin (MCH), and mean corpuscular hemoglobin concentrations (MCHC).

A complete blood count and leukocyte differential count are two of the most common clinical laboratory tests obtained in medical practice. Medical review of claims and physician documentation demonstrates general, widespread use as screening. In addition, the CBC is commonly used when an individual count within the CBC is desired.

Type of Bill: 12X, 13X, 14X, 22X, 23X, 71X, 74X, 75X

Revenue Codes: 300-319

Indications and Limitations of Coverage and/or Medical Necessity

  1. Indications for ordering/performing the CBC generally include anemia for which no cause is apparent, or the evaluation of marrow function.
  2. Specific indications for hematocrit and hemoglobin include signs/symptoms, test results, illness, or disease that can be associated with anemias (e.g., pallor, weakness, fatigue, positive fecal occult blood test, abnormal bleeding, malnutrition, neuropathy, known malignancy, polycythemia-primary or secondary, presence of acute or chronic disease that is known to have associated anemia, acute injury associated with blood loss or suspected blood loss, coagulation disorders, postural dizziness, abdominal pain, change in bowel habits, abnormal menstrual bleeding).
  3. Specific indications for WBC with or without differential count include fever, leukemia, infections or inflammatory process, etc.
  4. Specific indications for the platelet count include unexplained bleeding, ecchymosis, purpura, high risk drugs, etc.
  5. Blood counts are often routinely ordered whether a clinically relevant disease is present or not. Under the Medicare program, tests may be reimbursed only when a current or suspected disease state is present. Routine and screening studies are not reimbursable.
  6. Testing in the absence of physician signature/documentation which supports medical necessity for the tests will be denied by Medicare.

At the present time, this policy does not differentiate between those disease categories appropriate to red blood cells, white blood cells, platelet counts, etc. It is expected that the physician will order only the specific study relating to the problem present. To order a CBC when only a hemoglobin or a WBC count is needed is needed is improper. Post pay monitoring will be performed to ensure appropriateness of testing.

HCPCS Codes:

85007 Blood count; manual differential WBC count (includes RBC morphology and platelet estimation)
85008 manual blood smear examination without differential parameters
85009 differential WBC count, buffy count
85013 spun microhematocrit
85014 other than spun hematocrit
85018 hemoglobin
85021 hemogram, automated (RBC, WBC, Hgb, Hct, and indices only)
85022 hemogram, automated, and manual differential WBC count (CBC)
85023 hemogram and platelet count, automated, and manual differential WBC count (CBC)
85024 hemogram and platelet count, automated, and automated partial differential WBC count (CBC)
85025 hemogram and platelet count, automated, and automated complete differential WBC count (CBC)
85027 hemogram and platelet count, automated
85031 Blood count; hemogram, manual, complete CBC (RBC, WBC, Hgb, Hct, differential and indices)
85041 red blood cell (RBC) only
85044 reticulocyte count, manual
85045 reticulocyte count, flow cytometry
85048 white blood cell (WBC)
85595 Platelet; automated count

The following two CPT codes are not reimbursable by Medicare, (see “reasons for denial” section of this policy)

85029 Additional automated hemogram indices (e.g., red cell distribution width (RDW), mean platelet volume (MPV) – get details about MPV blood test, red blood cell histogram, platelet histogram, white blood cell histogram); one to three indices
85030 Platelet; automated count

ICD-9-CM Codes That Support Medical Necessity

Appropriate ICD-9 diagnoses which would underlie the need for blood counts are far too extensive to be specifically listed. Direct indications such as those listed above are among the following. More specific ICD-9 diagnosis codes of the underlying diagnosis should be provided when available. The following ICD-9 diagnosis codes are among those for which blood count testing may be reasonable.

Diagnosis Definition

ICD-9-CM Code Description
001.0 – 136.9
137.0 – 139.8
Infectious and Parasitic Diseases
140.0 – 239.9 Neoplasms
245.0 Disorders of Thyroid Gland
261
262
263.0 – 263.2
263.8 – 263.9
Nutritional Deficiencies
266.0 – 266.2
266.9
Deficiency of B-complex components
273.0 – 273.3
273.8 – 273.9
Disorders of Plasma Protein Metabolism
274.0
275.0
Disorders of Mineral Metabolism
277.1 Other and Unspecified Disorders of Metabolism
280.0 – 289.9 Diseases of the Blood and Blood-Forming Organs
320.0 – 326 Inflammatory Diseases of the Central Nervous System
362.81 Other Retinal Disorders
390 – 392.9 Acute Rheumatic Fever
415.0 – 415.19 Acute Pulmonary Heart Disease
430
431
432.0 – 432.9
434.00 – 434.91
Cerebrovascular Disease
444.0 – 444.9
446.0 – 446.7
Diseases of Arteries, Arterioles, and Capillaries
459.0 Diseases of Veins and Lymphatics, and other Diseases of Circulatory System
460 – 466.19 Acute Respiratory Infections
480.0 – 487.8 Pneumonia and Influenza
531.00,531.01
531.20,531.21
531.50
Gastric ulcer
Revised per Medicare Focus July, 2001
532.00,532.20
532.21,532.40
532.41
Duodenal ulcer
Revised per Medicare Focus July, 2001
533.00 – 535.61
537.82 – 537.83
Diseases of Esophagus, Stomach, and Duodenum
555.0 – 558.9 Noninfectious Enteritis and Colitis
562.00 – 562.13
566
567.0 – 567.9
569.3
569.82 – 569.85
Other Diseases of Intestines and Peritoneum
574.00 – 575.4
576.1
577.0
578.0 – 578.9
Other Diseases of Digestive System
590.00 – 590.81
593.81
599.7
Other Diseases of Urinary System
601.2
602.1
604.0 – 604.91
608.0
608.4
608.82
608.83
Diseases of Male Genital Organs
Note: 608.83 added per Medicare Focus December, 2001
611.0 Disorders of Breast
614.0 – 616.0
616.3 – 616.4
621.4
623.6
Inflammatory Disease of Female Pelvic Organs
626.0 – 627.1 Other Disorders of Female Genital Tract
633.0 – 633.2
633.8 – 633.9
Ectopic and Molar Pregnancy
634.00 – 634.02
634.10 – 634.12
634.50 – 634.52
635.00 – 635.02
635.10 – 635.12
635.50 – 635.52
637.00 – 637.02
637.10 – 637.12
637.50 – 637.52
638.00 Revised per Medicare Focus April, 2002
638.1 Revised per Medicare Focus April, 2002
638.10 – 638.12
638.5 Revised per Medicare Focus April, 2002
639.0 – 639.1
639.5
Other Pregnancy with Abortive Outcome
640.00 – 640.93
641.00 – 641.93
642.43
642.53
647.00 – 647.94
648.20 – 648.24
Complications Mainly Related to Pregnancy
658.40-658.41 Revised per Medicare Focus April, 2002 Normal Delivery, and Other Indications for Care in Pregnancy, Labor, and Delivery
660.00 – 667.14
669.10 – 669.44
Complications Occurring Mainly in the Course of Labor
670.00 – 670.04 Revised per Medicare Focus April, 2002
671.40 – 671.44
672.00 – 672.04
675.00 – 675.04
675.80 – 675.94
Complications of the Puerperium
680.0 – 686.9
695.2
695.4Added per MedicareFocus, November, 2001, pg. 29
696.0
Infections of Skin and Subcutaneous Tissue
710.0 – 710.9
711.10 – 711.49
712.10 – 712.39
713.1 – 713.3
714.0 – 714.9
716.90 – 716.99
719.10 – 719.19
719.40 – 719.49
Arthropathies and Related Disorders
720.0 -720.9
725
Dorsopathies
730.00 -730.09
730.10 – 730.19
730.20 – 730.29
Osteopathies, Chondropathies, and Acquired Musculoskeletal Deformities
759.0 Congenital Anomalies
762.1 Maternal Causes of Perinatal Morbidity and Mortality
772.0 – 772.9 Fetal and Neonatal Hemorrhage
776.0 – 776.9 Hematological Disorders of Fetus and Newborn
780.6
780.71-780.79
782.61
782.7
Symptoms
Revised per Medicare Focus, May 1999, pg. 12 and September, 1999
783.2 Symptoms Concerning Nutrition, Metabolism, and Development
784.7
784.8
Symptoms Involving Head and Neck
785.6 Symptoms Involving Cardiovascular System
786.03 Apnea [Exclude:sleep apnea (780.51, 780.53, 780.57)]
Added per MedicareFocus, June, 1999, pg. 27
786.04 Cheyne-Stokes respiration
Added per MedicareFocus, June, 1999, pg. 27
786.05 Shortness of breath
Added per MedicareFocus, June, 1999, pg. 27
786.06 Tachypnea [Exclude: transitory tachypnea of newborn (770.6)]
Added per MedicareFocus, June, 1999, pg. 27
786.07 Wheezing [Exclude: asthma (493.00-493.91)]
Added per MedicareFocus, June, 1999, pg. 27
786.09 Apnea; Cheyne-Stokes respiration; Respiratory: distress, insufficiency; Shortness of breath; Tachypnea; Wheezing
Added per MedicareFocus, August, 1998, pg. 24
786.3 Symptoms Involving Respiratory System and Other Chest Symptoms
789.00 – 789.09
789.2
Other Symptoms Involving Abdomen and Pelvis
790.0
790.92
792.1
Nonspecific Abnormal Findings
850.00 – 852.59 Subarachnoid, Subdural, and Extradural Hemorrhage, Following Injury
853.00 – 853.19 Other and Unspecified Intracranial Hemorrhage, Following Injury
860.0 – 869.1 Internal Injury of Thorax, Abdomen, and Pelvis
900-00 – 901.9 Injury to Blood Vessels
995.0
995.2
Other and Unspecified Effects of External Causes
996.60 – 996.69 Complications of Surgical and Medical Care, Not Elsewhere Classified
998.0
998.11
Other Complications of Procedures, NEC
V12.3 Persons with Potential Health Hazards Related to Personal and Family History
V58.0
V58.1
V58.61
V58.69
Persons Encountering Health Services for Specific Procedures and Aftercare
V67.0 – V67.2
V67.51
Persons Encountering Health Services in Other Circumstances
V72.81 – V72.83 Persons Without Reported Diagnosis Encountered During Examination and Investigation of Individuals and Populations

Category: Pathology and Laboratory

HCFA’s National Policy

Title XVIII of the Social Security Act, section 1862(a)(1)(A). This section allows coverage and payment for only those services that are considered to be medically reasonable and necessary, i.e., reasonable and necessary are those tests used in the diagnostic and management of illness or injury or improve the function of a malformed body part.

Title XVIII of the Social Security Act, section 1862(a)(7). This section excludes routine physical examinations.

Reason for Denial

  1. 85029 (additional automated hemogram indices (e.g., red cell distribution width (RDW), mean platelet volume (MPV), red blood cell histogram, platelet histogram, white blood cell histogram); one to three indices and 85030 (four or more indices) are not reimbursable as they are computerized calculations. Medicare does not pay for manual or automated percentage, ratios, or calculations.
  2. Blood tests for routine or screening purposes that are performed in the absence of signs, symptoms or personal history of disease are statutorily excluded from coverage.
  3. Tests that are not medically reasonable and necessary for the diagnosis and treatment of an illness or injury are not covered.