The Centers for Medicare and Medicaid Services (CMS) has announced a series of changes to the 2013 Fee Schedule. The changes will be effective on January 1, 2013. The most significant change is in the CPT code 88305 Technical Component (TC) which will be lowered by 52%. Although the professional component will be increased by 2%, the global payment for 88305 will decrease by 33%.
|Code||Modifier||Percent change 2013|
Although there is also a decrease in 88304, the changes in88305 initiated an outcry predominately among the reference, specialized surgical pathology laboratories, and in-office laboratories for understandable reasons, because 88305 is a biopsy code.
|Code||Modifier||Percent change 2013|
The increase in 88307 TC to 39%, as well as the TC immunohistochemistry to 14% (a significant part of the histology laboratory earnings) has gone unnoticed. However, the biopsy code 88305 TC is literally the bread and butter of most clinical histology laboratories. The entire table pertaining to changes of in CPT coding in the surgical pathology laboratory.
Partially, the CMS reaction was instigated by the enormous increase in the biopsies amount. There is a rational exuberance by clinicians and supporting them pathologist when a colonoscopy sometimes generated 12 specimens 88305×12 or a prostate biopsy included more than the standard six biopsies (besides the G codes for saturation). Although in most cases the biopsy is justified, such explosion has triggered the CMS gun.
The growth of in-office laboratories with the possibility to abuse the amount of necessary biopsies by circumventing the Stark law, also contributed to the CMS action. Here is a statement from an IOP’s ad (placed just at this website): “This is still an excellent investment for any GI, dermatology or multi-specialty group practice. Where else can you find an investment that has a return of six (6) months with a 40% profit margin in this stagnant economy?… Time to spread the wealth around for your benefit” (also a quote from this ad).If the laboratory is able to provide a 40% return, as the IOP states, the profit should come from somewhere. The reimbursement for the biopsies up utilization can be beneficial.
Although the commercial, “monoculture” laboratories, and in-office laboratories are most vocal in opposition to the CMS’s 88305 decision, the real collateral damage has been done by CMS to regular multispecialty laboratories, including those in teaching hospitals. 88305 represent not only tiny gastric or prostate biopsies, but more or less complicated and time consuming specimen. There can be numerous examples.
The product of conception (POC) is 88305. Often it is submitted entirely in10-15 cassettes.
Or prostate chips are also 88305. First 10 cassettes plus one additional for every ten grams is a common rule, but often the pathologist want to submit entirely ( I completely agree).
The list can be long.
The case study # 2 on this website can be shown as an example. The amputated toe is 88305; however significant y gross/histology work should be done before the pathologist’s diagnosis.
Although in general, not all payers (payors, as law and insurance industry uses this word) are at the mercy CMS regulations most insurance companies try to be in compliance especially if they have a stake in compliance due to the Medicare advantage program. Many insurance contracts are already linked to the Medicare fee schedule. Sooner rather than later the cuts will extend to all payers.
Eventually laboratories and clinicians will come to terms adjusting their practice as imposed on them by 88305 TC decrease in reimbursement. They can accommodate somehow the losses by expanding the amount immunochemistry. By increasing the reimbursing by 14 %, CMS gave them a hint. Rumors are that the next decrease will be in immunohistochemistry. Here is a quote from CAP TODAY (November 2012) feature article:” Next year, the CMS is expected to review the TC and PC of immunohistochemistry and enhanced cytology services as potentially overvalued.” It is doubtful seeing the tendency of increase reimbursement in 2013. Ventana and others would not be happy, if CMS goes for their turf. They are more powerful than IOPs. It looks like the additional measures of regulations will not be initiated, stopping with already made restrictions on the block/stain amount for reimbursement.
Hopefully, CMS would use for its regulation activity data that is provided by healthcare science and research. However, there is scarce material in this regard in the public domain.
The article “Pathology Economic Model Tool” about a novel approaches to workflow and budget cost (http://www.archivesofpathology.org/doi/pdf/10.1043/2000-0401-OA.1) is often mentioned among histotechnologists as a source, although it has nothing to do with biopsies processing productivity. There are informative articles on productivity in histology laboratory published by René Buesa in Annals of Diagnostic Pathology (11:137-41. 2007; 11:206-11. 2007; 13:322-33. 2009; 14:107-24. 2010; 14:182-93. 2010)http://www.histosearch.com/rene.html .
The feature article in CAP TODAY (November 2012) revealed the basic methodology approach to CMS decision making. Codes but not tests are reviewed for revaluation. Although this commonly accepted method by which CMS operates, the surgical pathology codes are different from others due to complicity and diversity of procedures which the codes represent. This makes them separate and only code valuation could be confusing and unsatisfying. The article opens also a little curtain by quoting Dr. Jonathan L. Myles, the Chair of the CAP’s Economic Affairs Committee: “The CAP has been working, and will continue to work, through the RUC [RVS Update Committee] process to minimize the impact on pathologists’ compensation.” Perhaps, both these approaches influenced the result- 88305 TC 52% decrease in the CMS reimbursement that targeted predominately histology laboratory. Who will care for the surgical pathology laboratory technical staff?
Federal Register published Medicare Program; Revisions to Payment Policies Under the Physician Fee Schedule, DME Face-to-Face Encounters, Elimination of the Requirement for Termination of Non-Random Prepayment Complex Medical Review and Other Revisions to Part B for CY 2013,
that tries to bring Price/Earning (PE) justification by objective criteria. Among many items there is a clause related to surgical pathology CPT coding (i) where American Medical Association AMA RUC made recommendations regarding new supply and equipment in direct (PE) input database. The most important for the 88305 TC subject is a paragraph that is reasonable to quote completely (in red italics with emphasis in bold some remarkable points):
In addition to this information, we are also seeking additional public comment regarding the appropriate assumptions regarding the direct PE inputs for these services. We note that the AMA RUC recommendations for these potentially misvalued codes were developed based on an underlying assumption regarding the typical number of blocks used each time a service is reported. The number of blocks assumed to be used has significant impact on the quantity of other supplies and the number of clinical labor and equipment minutes assigned as direct PE inputs to each code. After conducting an initial clinical review of these direct PE inputs, we are concerned that the number of blocks assumed for each code may be inaccurate. For 88300, no blocks are assumed. For 88302, one block is assumed. For 88304 and 88305, the assumed number of blocks typically used is 2. For 88307, the assumed number of blocks is 12 and for 88309, the typical number of blocks is assumed to be 18. We are accepting the AMA RUC’s recommended direct PE inputs that derive from these assumptions on an interim basis for CY 2013, but we are seeking independent evidence regarding the appropriate number of blocks to assume as typical for each of these services. We are requesting public comment regarding the appropriate number of blocks and urge the AMA RUC and interested medical specialty societies to provide corroborating, independent evidence that the number of blocks assumed in the current direct PE input recommendations is typical prior to finalizing the direct PE inputs for these services.
The health care reform law- Affordable Care Act- directed the CMS to review and speed up the process of revaluation. The CMS’s June 2012 decision was the result. However, there are ways to balance the work in surgical pathology laboratory and reimbursement.
CMS is a governmental regulatory agency that has limitations in the ability to manage complicated issues. It is not designed for a differential approach and its decisions depend on medical specialty association’s recommendations. This is the problem. The root of the problem is the AMA’s CPT coding Manual, rigid, out of touch with the everyday surgical pathology laboratory practice. The manual’s initial rational idea to classify through the coding complicity of the specimens and the amount of work/efforts to generate a pathologist’s diagnosis requires permanent updates and corrections. Instead we have the rare some cosmetic repairs or adjustment to a few new technologies.
88305 did not fall from the sky. Behind the 88305 numeral are standing real actions and work time. 88305 ought to be differentiated. CMS cannot do this, but the AMA’s CPT coding Manual can. The Manual can shift some denotations at different Levels (up code or down code), specify some descriptions, and clarify some ambiguous coding situations.
Let’s take dermatopathology as an example. The highest CPT coding is 88305 despite skin deep excisions for melanoma or skin cancer. Dermatopathologists are often frustrated with CPT coding and confused with some clinical coding variants. See Skin post, as well as Dimenstein IB “CPT Coding in Dermatopathology”, LabMedicine 2009;40:151-156.
Why Placenta Other than Third Trimester is 88305, that requires attention and work, but Placenta, Third Trimester is 88307?
Is the unlisted in the Manual Endoscopic mucosal resection 88305 biopsy?
The notorious Whipple procedure generates different coding approaches.
The lymph node regional resection vs. lymph node biopsy is also ambiguous.
This website presents a guidance CPT Coding in Surgical Pathology, a “cook book”, that provides “recipes” in form of coding case scenarios which might help cope with some difficulties in coding situations. However, in the end of the day the coding authorities have the upper hand in the interpretation of coding rules. Let me quote from a letter to me by Dennis Padget, the author of the Pathology Service Coding Handbook, the main expert in the field: “whether a physician or laboratorian agrees or disagrees with the AMA/CAP/CMS prescription for applying the CPT codes isn’t relevant—it’s the AMA/CAP/CMS prescription that must be applied if one is to avoid false claim refund, monetary penalty, and/or jail time. “ If not in jail, a loss of contract or embarrassment, for sure.
There cannot be any ambiguity in coding/charge business. The AMA CPT Coding Manual’s updating should go in parallel with other measures of CPT coding valuation in surgical pathology.
On this grossing technology website, the conclusion would sound as AMA CPT coding Manual’s surgical pathology section is ossified. The Manual needs decalcification to make it more flexible for rational adjustments to real life laboratories. This would fix 88305 failures and prevent debacles in the future.
On December 26, 2012, I sent a letter to the CAP TODAY Editor Sherrie Price. The letter has not been published. Below is this letter and the Editor’s answer on January 7, 2013. I have done what I could.
To the Editor:
The feature story’s part (November 20012) about high- volume code scrutiny in surgical pathology is revealing. Although it is understandable that codes are the CMS’s working tool, the surgical pathology valuation cannot be limited to pure coding without taking in consideration diversified tests which are behind six codes (88300, 88302, 88304, 88305, 88307, and 88309). The high- volume code is a euphemism for a test in greater demand than others. It is a matter of opinions and serious studies whether the tests are justified or exuberant, but the scrutiny merely of a code only imitates the surgical pathology laboratory practice with a predictable result.
88305-TC CPT code represents a variety of tests. Both a tiny gastric biopsy in one processing cassette is 88305×1 and a deep skin excision in melanoma with enormous amount of cassettes is also 88305×1. Or one core of sextant prostate needle biopsy (88305×6) in six cassettes and prostate chips in voluminous 40 grams specimen with at least 14 cassettes (only 88305×1). By the way, dermatopathology does not have any CPT code higher than Level IV 88305.This means that almost all histology laboratory revenue will have a 52% decrease.
However, the amount of cassettes/blocks, as a basic criteria, do not present a complete source for valuation .In the Federal Register’s document about revisions to Medicare Part B for CY13, the CMS accepted AMA RUC’ recommended direct PE inputs based on blocks count on an interim basis only for CY 2013. The document requested public comment on this issue
In my opinion that was formed by experience, the serious updating of the AMA CPT Coding Manual’s surgical pathology section is one of the urgent solutions. This section of the Manual has not been changed substantially for decades.
The CPT code 88305 TC issue and beyond is presented in more details on the website “Grossing Technology in Surgical Pathology” (www.grossing-technology.com). The question is discussed as a part of a comprehensive approach to CPT coding in surgical pathology.