Reimbursement Strategy 20042005

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The Happy Life of the Pathology
Practice Administrator
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Practice, Payment and Coding Issues 2004

• Or
• What is Up with CMS ?

PDAS Section Meeting presentation by Paul A.
Raslavicus, MD, MHA July 23, 2004
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(No Transcript)
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Objective of this presentation

• Pathology payment issues
• The Correct Coding Initiative (CCI)
• Adverse CMS initiatives
• Part A and part B issues
• Coding and pricing of the new technologies
• Opportunities and threats in pathology practice
• Overview of The Big Picture

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The Wheel of Fortune
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Public Policy Medicare Modernization Act

• 1.5 physician fee increase
• Five year clinical lab fee freeze
• Competitive bidding demonstration
• Oncology fee increases by legislation
• Section 942 procedures for new test pricing
• Two year histology granfather extension
• One year moratorium on PE recalculation
• New part B reassignment rules

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The CCI edits

• CCI edits involve pairs of CPT codes
• Mutually exclusive, or
• Codes within codes (components)
• CCI edits are applied to services
• billed by the same provider
• for the same beneficiary
• on the same date of service
• Indicators
• Use 59 Modifier to override edits for mutually
  exclusive edits

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National Correct Coding Initiative--CCI

• CMS Contractor AdminiStar
• Over 500 edits in Path and LM
• Web site www.cms.hhs.gov/physicians/cciedits/
• All edits are part OPPS for hospitals
• Recent focus on physician services and new
  technologies
• Our mind is made up
• Complaints fax Neils Rosen,MD [phone]

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CCI editsclinical labRecent examples

• 85027/85004 Automated differentials
• 80061/83721, 82465/83721 Lipids
• 80074/individual hepatitis antibodies
• Clinical pathology consults in microbiology
• Denies 88500 with 87269, 87660
• Modifier 91 Modifier -91 should be appended to
  laboratory procedure(s) or service(s) to indicate
  a repeat test or procedure on the same day.

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Recent CCI edits in physician fee schedule

• Specimens/Smears
• Frozen sections/Smears
• Surgical pathology consultations
• IHC/flow analysis
• IHC/tumor morphometry
• ISH/tumor morphometry
• ISH/cytogenetic codes (88271-75)

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CCI Specimens/cytology

• Excludes cytology (FNA and smears) when billed
  with surgical pathology (88160/2 and 88173 vs
  88304/9) when same diagnosis is rendered on same
  date
• Modifier overrides
• Different provider
• Different diagnosis
• Different specimen

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CCI Frozen sections/cytology-FNA

• 88329-32/88160-2 or 88173
• Edits on same specimen
• Permits use with 59 modifier
• CMS challenges full RVU for intraop cytology
• CMS challenges use of intraoperative
  consultation

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CCI Surgical pathology consultations

• Initially edits did not permit additional codes
  to consultation
• Now special studies allowed with modifier
• Documentation in the consultants report is key

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CCI Flow cytometry 88180 and IHC 88342

• CMS Considers services duplicative
• May use 59 modifier, but document!
• Different antibodies
• Challenge to standard practices
• Challenge to the unit of service (antibody)
• Coding changes for 2005
• Separation of TC codes from PC codes

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CCI IHC/Tumor Morphometry

• 88342/88358
• Denies payment for tumor morphometry by
  Chromavision
• Result2004 new code 88361
• Result two codes for 2005
• Pricing by PEAC/RUC underway

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ISH/Tumor morphometry

• Disallows tumor morphometry with ISH
  (88365/88358)
• Coding changes underway for 2005
• Two codes for manual and computer assisted
  techniques ISH morphometry
• Practice expenses submission to PEAC/RUC
• Work evaluation submissionfailed, re-do
  necessary

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CCI FISH/cytogenetics

• 88365 vs. 88271-75
• Issues raised
• Two ways to report same service
• CMS The sum is lesser than the parts
• Turf and payment issues
• Revised 88365 for 2005

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Challenge of coding for genetic disorders

• Currently
• In situ hybridization codes
• Molecular cytogenetics codes
• Molecular microbiology
• Molecular diagnostics generic codes
• Multiplex procedures (83901)definition?
• The future
• Codes for microarrays
• Codes for specific genetic disorders

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Genetic Test Coding Modifiers

• Solid tumor markers
• Lymphoid/hematopoetic neoplasms
• Non neoplastic hematology/coagulation
• Histocompatability
• Neurologic non neoplastic
• Muscular non neoplastic
• Metabolic
• Dysmorphology diseases

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Valuing costs and workThe RUC challenge

• The politics of RUC
• Costsa microcosting approach
• Submitted to PEAC/RUC then to CMS
• Adjusted through a top down process
• Workexpert panel or
• Survey process of 30pathologists
• Time for the service (intra, pre and post)
• Ranking of work effort (intensity)

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The RUC ChallengeImproving the Process

• Survey of practice costs
• Data on typical run size, failure rate, etc.
• Survey of professional work
• Education by experts
• Understanding the system
• Custom reference services
• Role of department chair
• Participation of academia is critical!

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CMS challenges

• The unit of service
• The same payment per unit of service
• The valuation of work (duplication of pre or
  post service work)
• Computer assisted image analysis
• Practice expenses moratorium expires 2005

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This months newsCMS moves against pathology

• Potential for transfer of physician services to
  the CLFS--
• Flow cytometry
• Tumor morphometry (manual and automated)
• Affected codes
• New five flow codes
• Revised ISH code
• New two morphometric analysis codes ISH
• Public hearing July 26
• Call in 877-357-7851 8402656

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Where is the ?

• Defeat the CMS proposal
• Be aggressive in the five year review
• Academic surgical pathology consultations
• Resist CCI attempts to redefine services
• Continue to codify new services
• New concepts in surgical pathology practice
• Consultation () vs. second opinion (QA)
• Appropriately code procedures
• Medicare approved screening tests
• Keep the specialty and our labs intact

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Challenges in the Scope of Practice

• CMS initiatives
• Weakening of part A and professional component
• Pharmacists
• Pathologists assistants
• Laboratory scientists
• Our clinical colleagues

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Clinician survival tool 1

• Client billing for AP
• CEJA exploits patients
• Stark law and Medicare anti kickback
• State fee splitting provisions
• Legislative Remedies
• Direct billingLA, NJ, RI, SC,
• Anti markupCA, NV, MI, OR
• Full disclosureAZ, CT, MD, ME, PA, TN,VT

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Clinician survival tool 2

• The POD lab phenomenon
• Purchased TC can not be marked up
• If TC is performed, PC can be marked up
• Histology not a CLIA service
• New claim reassignment rules for physician
  services
• Need not be on premises (in office)
• Contractor in same carrier region
• Joint and several liability for claims

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The Macro View

• Economics is the principal driver, value is
  second
• Decreasing payment per unit of work
• Consolidation and regionalization for
  productivity gain and market clout
• The stars will shine, the cows will be butchered
• Be or be-ware the niche player
• Name branded pathology
• Stick close to the patient and his physician
• Embrace new tech, new paths

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The Happy Life of the Pathology
Practice Administrator???