Diana W. Voorhees, M.A. CLS, MT, SH, CLCP Principal/CEO DV & Associates, Inc. firstname.lastname@example.org 801.272.3672
Discuss Coding Changes for 2011 including CPT, HCPCS, and ICD-9 Describe latest changes to CCI Indicate projected reimbursement for 2011 Discuss pertinent policies and issues affecting laboratory and pathology billing and reimbursement DV & Associates, Inc.3
New codes reimbursed under the CLFS and MPFS Recommendations under CLFS are crosswalk or gapfill Reconsideration requests for 5 codes Include deletions and description changes DV & Associates, Inc.4
HCPCS G0430Drug screen, qualitative; multiple drug classes other than chromatographic method, each procedure ◦ No comments ◦ Scheduled for deletion 5DV & Associates, Inc.
HCPCS G0431 Drug screen, qualitative; single drug class method (e.g., immunoassay, enzyme assay), each drug class ◦ No comments ◦ Providers requesting an examination of payment levels for the two “G” codes ◦ Is it fair to reimburse “kits” the same amount regardless of the number of classes tested? ◦ 80101 not likely to be recognized again by Medicare ◦ Code G0431 apply only to CLIA high complexity laboratories; G0430x5 = $104.15 DV & Associates, Inc.6
CPT 80104Drug screen, qualitative; multiple drug classes other than chromatographic method, each procedure ◦ This code takes the place of G0430 ◦ One organization suggested CPT 80101 ($19.72) and three others suggested G0430 ($20.83) ◦ Apply to CLIA regulated facilities only? DV & Associates, Inc.7
HCPCS GXXX1Drug screen, other than chromatographic; any number of drug classes, per specimen ◦ No recommendations detected ◦ Use for CLIA waived testing ◦ Xwalk to G0430 and $20.83 DV & Associates, Inc.8
CPT 82930 Gastric acid analysis, includes pH if performed, each specimen ◦ Four organizations recommended CPT 82928 ($9.38 ) DV & Associates, Inc.9
82926 Gastric acid, free and total, each specimen 82928 Gastric acid, free or total, each specimen 10DV & Associates, Inc.
CPT 83861 Microfluidic analysis utilizing an integrated collection and analysis device, tear osmolarity ◦ One organization recommended a gapfill, based on the manufacturer’s costing analysis ◦ Xwalk to 83909 and $24 ◦ Sets the scene for coding other procedures using similar devices and thus the outcome can be significant ◦ New parenthetical comment indicates code is per eye; If both eyes, report twice DV & Associates, Inc.11
CPT 84112 Placental alpha microglobulin-1 (PAMG-1), cervicovaginal secretion, qualitative ◦ Five organizations recommended CPT 82731 (fetal fibronectin ($92.26)) ◦ Amnisure Rupture Of Membranes (ROM) test ◦ Rapid, no instrument, qualitative, monoclonal antibodies ◦ Immunochromatographic in vitro detection of the protein PAMG-1 ◦ Present in cervico-vaginal discharge following rupture of the [fetal] membranes ◦ Identify preterm labor DV & Associates, Inc.12
CPT 85598 Phospholipid neutralization; hexagonal phospholipid ◦ Three organizations recommended CPT 85597 (platelet neutralization ($25.75)) ◦ Confirmatory test for Lupus anticoagulants DV & Associates, Inc.13
CPT 86481 Tuberculosis test, cell mediated immunity antigen response measurement; enumeration of gamma interferon-producing T-cells in cell suspension ◦ Four organizations recommended CPT 86480 (Tuberculosis test, cell mediated immunity measurement of gamma interferon antigen response ($88.77) and the other recommended CPT 86480 + 86359 (total T cells) ($142.80 total) DV & Associates, Inc.15
86480Tuberculosis test, cell mediated immunity antigen response measurement; of gamma interferon antigen response 16DV & Associates, Inc.
CPT 86902 Blood typing; antigen testing of donor blood using reagent serum, each antigen test ◦ Four organizations recommended CPT 86903 (Blood typing; antigen screening for compatible blood unit using reagent serum, per unit screened ($13.52)) ◦ New parenthetical comment indicates if multiple blood units are tested for the same antigen, code should be reported for each antigen for each unit tested DV & Associates, Inc.17
86903 Blood typing; antigen screening for compatible blood unit using reagent serum, per unit screened 18DV & Associates, Inc.
CPT 87501 Infectious agent detection by nucleic acid (DNA or RNA); influenza virus, reverse transcription and amplified probe technique, each type or subtype ◦ Three organizations recommended CPT 87798 (NOS ($50.27)) + 83902 (RT) ($70.60 total) DV & Associates, Inc.19
CPT 87502 Infectious agent detection by nucleic acid (DNA or RNA); influenza virus, for multiple types or sub-types, reverse transcription and amplified probe technique, first 2 types or sub-types ◦ One organization recommended CPT 87798x2 and 83902x2 ($217.20) ◦ Four organizations recommended CPT 87801 (multiple organisms PCR ($100.54)) + 83902 ($120.87 total) DV & Associates, Inc.20
CPT +87503 Infectious agent detection by nucleic acid (DNA or RNA); influenza virus, for multiple types or sub-types, multiplex reverse transcription and amplified probe technique, each additional influenza virus type or sub-type beyond 2 (List separately in addition to code for primary procedure) ◦ Note add on code ◦ One organization recommended CPT 87798 + 83902 ($70.60) ◦ Three organizations recommended CPT 83901 + 83896 ($29.75) DV & Associates, Inc.21
CPT 87906 Infectious agent genotype analysis by nucleic acid (DNA or RNA); HIV-1, other region (eg, integrase, fusion) ◦ Five organizations recommended CPT 87901 (genotype, nucleic acid, HIV-1, RT and protease ($368.73)) DV & Associates, Inc.22
87901 Infectious agent genotype analysis by nucleic acid (DNA or RNA); HIV-1, reverse transcriptase and protease regions 23DV & Associates, Inc.
HCPCS G0432 Infectious agent antibody detection by enzyme immunoassay (EIA) technique, HIV-1 and/or HIV-2, screening ◦ Four organizations recommended CPT 86702 (Antibody, HIV-1 and HIV-2, single assay ($19.65) 24DV & Associates, Inc.
HCPCS G0433 Infectious agent antibody detection by enzyme-linked immunosorbent assay (ELISA) technique, HIV-1 and/or HIV-2, screening ◦ Four organizations recommended CPT 86702 (Antibody, HIV-1 and HIV-2, single assay ($19.65) DV & Associates, Inc.25
HCPCS G0435 Infectious agent antibody detection by rapid antibody test, HIV-1 and/or HIV-2, screening ◦ Four organizations recommended CPT 86702 (Antibody, HIV-1 and HIV-2, single assay ($19.65) DV & Associates, Inc.26
CPT 88749Unlisted in vivo (eg, transcutaneous) laboratory service 27DV & Associates, Inc.
+82952 Glucose; tolerance test, each additional beyond 3 specimens (List separately in addition to code for primary procedure) ◦ Note add on code 28DV & Associates, Inc.
CPT 84145 Procalcitonin (PCT) ◦ No discussion detected ◦ CLFS NLA $27.76 ◦ Xwalk to calcitonin (82308) and $38.36 29DV & Associates, Inc.
CPT 84431 Thromboxane metabolite(s), including thromboxane if performed, urine ◦ No discussion detected ◦ CLFS NLA $18.54 ◦ Creatinine may also be billed $7.41 ◦ Xwalk to TSH and $24.06 DV & Associates, Inc.30
CPT 86352 Cellular function assay involving stimulation (e.g., mitogen or antigen) and detection of biomarker (e.g., ATP) ◦ Two organizations recommended gapfill ◦ Obtain costing information ◦ Xwalk to phytomitogen (86353x2) + chemilluminescence (82397x2) = $180.92 DV & Associates, Inc.31
89100 Duodenal intubation and aspiration; single specimen (eg, simple bile study or afferent loop culture) plus appropriate test procedure 89105 collection of multiple fractional specimens with pancreatic or gallbladder stimulation, single or double lumen tube 32DV & Associates, Inc.
89130 Gastric intubation and aspiration, diagnostic, each specimen, for chemical analyses or cytopathology; 89132 after stimulation DV & Associates, Inc.33
89135 Gastric intubation, aspiration, and fractional collections (eg, gastric secretory study); 1 hour 89136 2 hours 89140 2 hours including gastric stimulation (eg, histalog, pentagastrin) 89141 3 hours, including gastric stimulation DV & Associates, Inc.34
89225 Starch granules, feces 89235 Water load test DV & Associates, Inc.35
88120Cytopathology, in situ hybridization (eg, FISH), urinary tract specimen with morphometric analysis, 3-5 molecular probes, each specimen; manual 88121Cytopathology, in situ hybridization (eg, FISH), urinary tract specimen with morphometric analysis, 3-5 molecular probes, each specimen; using computer- assisted technology DV & Associates, Inc.36
CPT 88120 and 88121, Cont. ◦ Parenthetical comments that morphometric FISH on non-urinary cytologic specimens apply to 88367 and 88368 ◦ More than 5 probes should be coded with CPT 88399 ◦ Parenthetical comment following CPT 88368 refers evaluation of urinary tract specimens to CPT 88120 or 88121 37DV & Associates, Inc.
88172 Cytopathology, evaluation of fine needle aspirate; immediate cytohistologic study to determine adequacy of specimen(s) for diagnosis, first evaluation episode, each site ◦ New parenthetical comment that an episode is a complete set of cytologic material submitted for evaluation and is independent of the number of needle passes or slides prepared. Separate episode occurs if the proceduralist obtains additional material from the same site based on the prior immediate evaluation or a separate lesion is aspirated 38DV & Associates, Inc.
CPT +88177 Cytopathology, evaluation of fine needle aspirate; immediate cytohistologic study to determine adequacy for diagnosis, each separate additional evaluation episode, same site (List separately in addition to code for primary procedure) ◦ Note an add on code ◦ Resequenced DV & Associates, Inc.39
CPT +88177, Cont. ◦ Parenthetical comment indicates the code is used when repeat evaluation episode(s) is required on subsequent cytologic material from the same site Prior sampling not adequate 40DV & Associates, Inc.
88363Examination and selection of retrieved archival (ie, previously diagnosed) tissue(s) for molecular analysis (eg, KRAS mutational analysis) ◦ Review of archived sample to select blocks most appropriate for molecular study ◦ Does not include microdissection or molecular interpretation DV & Associates, Inc. 41
HCPCS G9143 Pharmacogenomic testing for Warfarin response ◦ No recommendations detected ◦ Xwalk to 83891 + 83896x3 + 83900 + 83901 + 83908x3 + 83912 = $172.76 DV & Associates, Inc.42
+88332 Pathology consultation during surgery; each additional tissue block with frozen section(s) (List separately in addition to code for primary procedure) ◦ Note add on code ◦ Use with CPT 88331 +88334 cytologic examination (eg, touch prep, squash prep), each additional site (List separately in addition to code for primary procedure) Note add on code; Use CPT 88334 with 88331, 88333 DV & Associates, Inc.43
Molecular Modifiers ◦ ▲4A HLA-A* ◦ ▲4B HLA-B* ◦ ▲4C HLA-C* ◦ (Modifier 4D has been deleted) HLA D ◦ ▲4E HLA-DRB all ◦ # ●4P HLA-DRB1* ◦ # ●4Q HLA-DRB3* DV & Associates, Inc.44
Genetic Modifiers Renumbering ◦ # 4P Modifier is out of numerical sequence. See Modifier 4A-4Z ◦ # 4Q Modifier is out of numerical sequence. See Modifier 4A-4Z ◦ # 4R Modifier is out of numerical sequence. See Modifier 4A-4Z DV & Associates, Inc. 46
Molecular Modifiers ◦ # 4S Modifier is out of numerical sequence. See Modifier 4A-4Z ◦ # 4T Modifier is out of numerical sequence. See Modifier 4A-4Z ◦ # 4U Modifier is out of numerical sequence. See Modifier 4A-4Z DV & Associates, Inc. 47
287.4Secondary thrombocytopenia Add 287.41 Post-transfusion purpura 287.49 Other secondary thrombocytopenia DV & Associates, Inc.48
780.6 Fever and other physiologic disturbances of temperature regulation Add 780.66 Febrile nonhemolytic transfusion reaction DV & Associates, Inc.49
275.0 Disorders of iron metabolism ◦ Invalid and replace it with the following: 275.01 Hereditary hemochromatosis 275.02 Hemochromatosis due to repeated red blood cell transfusions 275.09 Other disorders of iron metabolism 275.03 Other hemochromatosis DV & Associates, Inc.51
488.0Influenza due to identified avian influenza virus 488.1Influenza due to identified novel H1N1 influenza virus Add 488.01Influenza due to identified avian influenza virus with pneumonia 488.02Influenza due to identified avian influenza virus with other respiratory manifestations DV & Associates, Inc.52
◦ 488.09Influenza due to identified avian influenza virus with other manifestations ◦ 488.11Influenza due to identified novel H1N1 influenza virus with pneumonia ◦ 488.12Influenza due to identified novel H1N1 influenza virus with other respiratory manifestations ◦ 488.19Influenza due to identified novel H1N1 influenza virus with other manifestations DV & Associates, Inc.53
Examples: Added ◦ 999.62ABO incompatibility with acute hemolytic transfusion reaction ◦ 999.63ABO incompatibility with delayed hemolytic transfusion reaction ◦ 999.71Rh incompatibility with hemolytic transfusion reaction not specified as acute or delayed ◦ 999.72Rh incompatibility with acute hemolytic transfusion reaction ◦ 999.85Delayed hemolytic transfusion reaction, incompatibility unspecified DV & Associates, Inc.55
CPT 88312, 88313, 88342, 88360 & 88361 The unit of service for special stains is each stain “If it is medically reasonable and necessary to perform the same stain on more than one specimen or more than one block of tissue from the same specimen, additional units of service may be reported for the additional specimen(s) or block(s).” DV & Associates, Inc.56
“Physicians should not report more than one unit of service for a stain performed on a single tissue block. For example it is common practice to cut multiple levels from a tissue block and stain each level with the same stain. The multiple levels from the same block of tissue stained with the same stain should not be reported as additional units of service. Only one unit of service should be reported for the stain on multiple levels from the single tissue block.” DV & Associates, Inc.57
Clarity in use of stains and UOS “Physicians should not report more than one unit of service for a stain performed on a single tissue block. For example it is common practice to cut multiple levels from a tissue block and stain each level with the same stain. The multiple levels from the same block of tissue stained with the same stain should not be reported as additional units of service. “ DV & Associates, Inc.58
Stains, Cont. “Only one unit of service should be reported for the stain on multiple levels from the single tissue block.” “For cytology specimens from a single anatomic site only one unit of service may be reported for each special stain regardless of the number of slides from that site stained with the special stain.” 59DV & Associates, Inc.
“Additionally, controls performed with special stains should not be reported as separate units of service for the stain.” Use caution and document staining exercise DV & Associates, Inc.60
CPT Assistant, October 2010 Question ◦ We received two blocks, both labeled ABC09-1234 (C & D). We performed CD20 and CD45 on both blocks. Would we code this scenario as 88342 x2 or x4? Response ◦ CPT 88342, each antibody, should be reported twice. It is “each antibody” no matter how many blocks are applied to a given specimen 61DV & Associates, Inc.
Transmittal R1921CP, 2/19/10 Voluntary versus mandatory ABN NEMB blended into ABN ◦ Advanced Beneficiary Notice of Noncoverage (ABN) Effective Date: April 1, 2010 Implementation Date: April 5, 2010 DV & Associates, Inc.62
GA Waiver of liability statement issued as required by payer policy ◦ Mandatory use ◦ Submitted with covered charges ◦ Medicare will now deny these claims as a beneficiary liability (CO-50) ◦ No medical review ◦ Beneficiary have the right to appeal ◦ Changed September 17, effective last April 1, Transmittal 770 Suspension of automatic denial with -GA DV & Associates, Inc.63
July 15, 2009 Bureau of Labor Statistics ◦ Consumer Price Index (urban) = -1.4% Less 0.5% ◦ Medicare Improvement for Patients and Providers Act (MIPPA) 0.5% below the CPI for urban consumers through 2013 Overall adjustment -1.9% ◦ First negative adjustment DV & Associates, Inc.64
June 30, 2010 Bureau of Labor Statistics ◦ Consumer Price Index (urban) = +1.1% Less productivity adjustment ◦ Estimated at 1.3% ◦ Negative 0.2% ◦ Cannot go below 0% adjustment Less 1.75% starting 2011 ◦ Overall projected adjustment -1.75% ◦ Second negative adjustment DV & Associates, Inc.65
December 1, 2010 without Congressional change, -23.5% payment (SGR) The Physician Payment and Therapy Relief Act of 2010, passed Senate on November 18 but still requires House passage and the president's signature. ◦ Once signed, seniors and military families are spared the threat of a lapse in care till the end of the year DV & Associates, Inc.66
On January 1, 2011 without congressional action: ◦ Another -6.1 % for 2011 (SGR) ◦ Total – 29.6% plus whatever happens to component RVUs 67DV & Associates, Inc.
CMS already announced end of TC billing provision Fought by various laboratory & pathology groups 71DV & Associates, Inc.
CMS finalizing policy to require ordering provider’s signature on requisitions for clinical diagnostic laboratory tests reimbursed under the Medicare Part B CLFS ◦ Only affects paper requisitions Various manuals being reconfigured to reflect requirement ◦ Effective January 1? ◦ Still under siege by laboratory organizations DV & Associates, Inc.72
Test order can be any of the following formats: ◦ A written document, signed by the treating physician/practitioner, that is hand-delivered, mailed, or faxed to the testing facility ◦ A telephone call by the treating physician/practitioner or his or her office to the laboratory ◦ Electronic mail, or other electronic means, by the treating physician/practitioner or his or her office to the laboratory DV & Associates, Inc.73
If the order is via telephone, both the treating provider or provider’s office and the laboratory must document the telephone order in their respective copies of the beneficiary’s medical record Policy is thought to document a clear order and assist with compliance Signature requirement is not supposed to be a burden to providers since they need to sign orders anyway DV & Associates, Inc.74
Provider Enrollment, Chain, and Ownership Chain ◦ Precipitated by Patient Protection and Affordable Care Act (PPACA) ◦ Goal is to keep fraudulent entities from billing Federal healthcare programs ◦ Ordering and referring physicians must be enrolled in Medicare by July 1, 2010 Or appropriately “opted out” Identified on claim Deadline extended to 2011 DV & Associates, Inc.75
Document orders/referrals for 7 years or lose enrollment for 1 year Referrals could be denied if ordering physician not updated Potentially, pathologists who lack update in enrollment may have internal orders internal denied Includes: ◦ Address changes, complete physician name match, CLIA information “Drive by” site visits DV & Associates, Inc.76
Small Business Lending Act includes an anti-fraud provision ◦ Sponsored by Sen. LeMieux of FL ◦ Signed by President on September 27 ◦ Medicare start competitive bidding for “predictive modeling” software contractors by January and implement first in the 10 worst fraud states ◦ Goal to quit “pay and chase” to “first weigh and then pay” ◦ Suspend payments to a provider where “credible allegation” of fraud DV & Associates, Inc.77
Medicare just awarded grants to >50 Senior Medicare Patrol Programs (SMPs) ◦ Increase awareness of M & M beneficiaries of fraud prevention, identification, and reporting ◦ Increased funding for states known for high fraud areas ◦ Administered by Administration on Aging DV & Associates, Inc.78