CAP Clarifies IHC Billing Policies for CPT, Medicare
Pathologists are facing new challenges billing immunohistochemistry (IHC) services for both government and commercial payers. To promote further understanding of new policies under the American Medical Association (AMA) Current Procedural Terminology (CPT) and the Centers for Medicare & Medicaid Services (CMS), the CAP continues to provide education on these changes to its members.
For 2014, CPT introduced a new code for IHC, 88343. This code was to be used as an add-on to 88342, per antibody, for multiplex staining, which is when multiple antibodies are applied to a single slide, distinguished by chromophore (eg, red versus brown) or localization (eg, nuclear versus cytoplasmic). 88342 is used when billing single stains (when a single antibody is applied to a slide) and for the first separately identifiable stain in a multiplexed IHC stain.
The CPT unit of service for both these codes was specified to be per antibody, per block—an important distinction when considering the new Medicare G codes.
Even though the amount payable for both the 88342 and the 88343 was reduced for these new CPT descriptions, Medicare was concerned that this would lead to an increase in total payments for IHC. The Medicare agency then specified in the 2014 Medicare Physician Fee Schedule that they would not accept either CPT code.
However, commercial payers may still accept CPT codes. The CAP has urged members to confirm which codes insurers require when billing IHC services.
Instead of 88342 and 88343, CMS elected to create HCPCS level II G codes “to ensure that the services are only reported once for each antibody per specimen.” The CAP continues to oppose the Medicare policy and is working with CMS to address members’ concerns.
The CAP’s current understanding is that G0461 (specimen being defined by CPT/HCPCS as “tissue or tissues that is (are) submitted for individual and separate attention, requiring individual examination and pathologic diagnosis”) is for the first single or multiplex antibody stain on a specimen, and G0462 is for each subsequent single or multiplex antibody stain after the first on a specimen, irrespective of whether the stains were single or multiplex.
Medicare further instituted National Correct Coding Initiative (NCCI) guidelines limiting one unit of service for each separate specimen when a single immunohistochmical/immunocytochemistry stain for one or more antibodies is performed on multiple blocks from a surgical specimen. Physicians should not report more than one unit of service per specimen for an immunohistochemical/immunocytochemistry antibody stain when it contains multiple separately interpretable antibodies. Physicians may report G0461 for the first stain on a specimen. Each additional stain on the same specimen is reported with G0462.
The bifurcated nature of coding for IHC is clearly disruptive to pathologists, histology departments, and pathology billers. The following vignettes illustrate the differences of these coding systems:
Vignette #1: Microscopic examination of a CD15 immunohistochemical antibody stain performed on blocks A1 and A2 of a cervical lymph node with suspected Hodgkin lymphoma.
To CPT code this service, one would use 2 units of 88342, as the unit of service for this code is the separately identifiable antibody per surgical block, cytologic preparation, or hematologic smear.
To HCPCS code this service, one would use 1 unit of G0461, as the unit of service for this code is each antibody per specimen.
Vignette #2: Microscopic examination of an immunohistochemical cocktail of P504S and HMWK (34ßE12) performed on two prostate needle core biopsies (designated “LA” and “RA”) from a 66-year-old male with elevated PSA that underwent a six-part transrectal prostate needle biopsy procedure.
To CPT code this service, one would use 2 units of 88342 and 2 units of 88343. The first instance of a 88342/3 pair is used to code for the multiplex stain for the first stained (“LA”) specimen and the second instance of a 88342/3 pair to code for the second stained (“RA”) specimen.
To HCPCS code this service one would use 2 units of G0461; although the unit of service for this code is each antibody per specimen, the above NCCI guidelines limit billing of second or subsequent antibody stains on the same slide.
The CAP is fully aware of the difficulties that this bifurcated coding system creates and is working diligently with both CPT and CMS to create a single appropriate coding system for immunohistochemical services. However, it is highly unlikely that any significant coding modifications will occur in 2014.
Virginia Lawmakers Unanimously Approve Anti-Markup Bill
Legislation to protect patients from inflated medical bills for pathology services has unanimously passed the Virginia legislature with the support of the CAP and the Virginia Society of Pathologists.
Under the legislation (HB 893), Virginia patients would be protected from higher medical bills for any form of biopsy or Pap smear tests. Without the legislation, a physician who ordered these services could increase the cost of the service when an outside laboratory or pathologist performs it.
The CAP supports Virginia’s anti-markup bill, in addition to direct billing for anatomic pathology services. Optimally, the CAP believes payment for anatomic and clinical pathology services should be made only to the person or entity that performed or supervised the service, except for referrals between laboratories independent of a physician’s office.
AMA ethics policies expressly condemn markup business practices, but until the new law is enacted there is no legal prohibition in the state.
With enactment, Virginia will become the 25th state to expressly outlaw such markup billing practices either through direct billing or anti-markup laws. Gov. Terry R. McAuliffe has not signed the measure at this article’s deadline, but he is expected to sign it into law. The legislation was sponsored in the legislature by Rep. Christopher P. Stolle (R) of Virginia Beach and Norfolk.
Policy Meeting Speaker: World’s Experts on Diagnosis Are Critical for ACO Success
In advance of his keynote speech for the 2014 CAP Policy Meeting , Dartmouth’s Elliott S. Fisher MD, MPH, emphasized the importance of pathology participation in accountable care organizations (ACOs).
In general, ACOs strive to improve and provide integrated care and reduce costs for a defined population of patients. ACO participants are held accountable for the total cost and quality of care for their assigned patient group.
Dr. Fisher noted at least two significant roles pathologists have to improve quality and contain spending within the ACO model. First, pathologists possess the scientific knowledge to ensure important diagnoses are not missed so primary care physicians and specialists avoid not only overtreatment but undertreatment, too. And pathologists work to improve laboratory processes so samples are tested as quickly as possible.
“Pathologists are the world’s experts on diagnosis strategies,” Dr. Fisher, who serves as director of The Dartmouth Institute for Health Policy & Clinical Practice, told STATLINE. “They can make sure there are the best tools available to support frontline clinicians to make a wise diagnosis. It’s right there for them to contribute and make improvements.”
The CAP has been an active member of the Brookings-Dartmouth ACO Learning Network, which is led by Dr. Fisher and former CMS Administrator Mark McClellan, MD. Dr. Fisher applauded the CAP for its four years of participation in the network. It is an opportunity for members—which include physician organizations, hospitals, insurers, and manufacturers—to connect, learn, and develop best practices, Dr. Fisher said.
The CAP has extensive information on coordinated care programs in its ACO/Coordinated Care Resource Center, including tools to assist pathologists. If you work at one of the new Medicare Shared Savings Program (MSSP) ACOs or work at an organization that is currently, or will be part of an ACO, we encourage you to join the CAP’s ACO network by sending us an email.
Recent preliminary financial results show MSSP ACOs generated $128 million in savings to the Medicare trust fund during the first 12 months. Beginning in 2012, nearly half of the 114 groups lowered costs during the first year. However, only 29 groups reduced spending and earned shared savings bonuses.
CMS has stated that ACOs are designed to generate savings over several years. An analysis of 23 large organizations, with more experience in the payment model, participating in the Pioneer ACO program showed they saved $147 million during the first year. Nine of the Pioneer ACOs had reduced spending significantly and exceeded quality-reporting requirements, according to CMS.
CMS also has published online the quality measure performance data during 2012 for 141 Medicare ACOs. Although there are 33 measures that ACOs reported, only the results of five measures were published: four involving diabetes and another on cardiac care. The results were varied.
Legislation to Enhance Pathologist ACO Role Gains Patient, Physician Organization Supporters
Four more physician and patient advocacy groups announced their support for state legislation that would help ensure access to appropriate clinical laboratory and pathology services delivered in ACOs.
The CAP and state pathology societies, advocating for the legislation in three states, welcomed statements urging passage from the Leukemia and Lymphoma Society, American Society of Breast Disease, Association of Molecular Pathology, and Association of Pathology Chairs. State ACO legislation is pending in California (SB 264), Illinois (HB 2544), and New Jersey (AB 4302).
“Pathologists, by virtue of their education, training, and professional expertise, bring unique value to ACOs, particularly in helping these entities in pursuit of quality and appropriate utilization of laboratory testing,” the Association of Pathology Chairs said in a January 31 letter. “Moreover, in our opinion, robust pathologist integration into ACOs medical decision-making, as it relates to all aspects of the clinical laboratory will not only optimize medical quality but also has significant potential to advance medical science in the origins and treatment of disease through personalized medicine delivered through genetic-testing innovations and targeted-treatment adoptions.”
If enacted, at least one physician clinical laboratory medical director serving the ACO would be required to participate in newly created clinical laboratory testing advisory boards and recommend protocols for appropriateness of pathology and laboratory testing. The advisory boards would aim to ensure that patients have access to all medically necessary testing.
“While as physicians and advocates we push forward advances in medical science, we also seek to ensure that all patients, including those with cancer, receive all medically necessary laboratory and pathology testing to diagnose and treat their illness to the best of our current medical knowledge,” the CAP and patient groups stated in a February 11 letter.
The four physician and patient groups joined the Lung Cancer Alliance, the National Brain Tumor Society, and California Medical Association to support the legislation.
Most Laboratories Use Interfaces to Send Test Results Electronically
A CAP-supported federal study found two-thirds of clinical laboratories, with most using electronic interfaces, have the capability to send structured test results to ordering physician electronic health record (EHR) systems.
The CAP had encouraged its members to participate in an HHS Office of the National Coordinator (ONC) for Health Information Technology survey, which provides a benchmark for pathologists. Results were released in a February 21 data brief and ONC acknowledged the CAP for its assistance in the survey’s development and during the initial outreach. The data can assist the College to guide federal officials on drafting policies for laboratory information exchange.
Sending structured test results to ambulatory providers is a key requirement under stage 2 of the Medicare EHR Incentive program meaningful use standards. Physicians who first participated in the program in 2011 or 2012 moved to stage 2 in 2014.
The survey results also reported on common challenges for sending test results electronically. They included high subscription rates for exchange services providers (19%) and the lack of harmonization of industry accepted standards (17%). Other key findings include:
- Three-quarters of laboratories shared test results electronically, which includes structured or unstructured data.
- A total of 56% shared test results through an interface to an EHR. Other mechanisms were a laboratory web portal (26%) or a third party (22%).
- Approximately one in 10 laboratories reported that their primary challenge was confronting EHR systems unable to receive structured test results.
ONC also released a data brief on patient access to their laboratory results. Three in 10 laboratories allowed patients or their legal guardians to access clinical test results directly. Among laboratories providing electronic access to patients, mechanisms for sharing test results included Web portals provided by laboratories (41%), physician’s EHR that provides patient access (39%), transmission of results to a personal health record (38%), and through a health information organization (10%).
The patient survey was published before HHS finalized regulations, which included several CAP recommendations, expanding access to laboratory test results.
Concerned About Payment Penalties? Register for CAP Webinar on PQRS
Register for the CAP’s upcoming webinar, “PQRS: What You Need to Know (And Do!) in 2014,” on Monday, March 31, at 2:00 PM ET.
The webinar features the CAP’s Economic Affairs Committee experts who will advise you on how to earn 2014 Physician Quality Reporting System (PQRS) incentives and prevent future Medicare penalties. The webinar is free to CAP members.
As a result of the CAP’s advocacy, CMS has promised NOT to penalize pathologists who have no PQRS measures that apply to their practice. But to confirm that you’re eligible for this exemption, you must act.
The webinar will discuss who is and is not at risk of the PQRS penalties, as well as how to confirm which PQRS measures apply to your practice.
Register today for “PQRS: What You Need to Know (And Do!) in 2014.”
202-354-7100 • 202-354-8101 (fax) • 800-392-9994