Pathology/Lab Coding Alert

Payment levels net little change.

Pricing isn’t the only thing you need to look out for when you evaluate the 2014 Clinical Laboratory Fee Schedule’s (CLFS) impact on your lab. Two CMS plans that aim to change the way codes are valued and the way you get paid for lab tests could have an even larger impact on your bottom line.

Look at the following synopsis to see what the CLFS final rule holds in store (published in the Dec. 10, 2013 Federal Register).

Check Overall Pay Change

You can expect a negative 0.75 percent total payment update for services paid on the CLFS in 2014.

“That’s a pretty minor change compared to recent years,” says William Dettwyler, MTAMT, president of Codus Medicus, a laboratory coding consulting firm in Salem, Ore. For instance, the CLFS saw a negative 4.95 percent adjustment in 2013.

The net change in payment rates is due to a -1.75 percent annual adjustment for the Affordable Care Act (ACA), a positive 1.8 percent Consumer Price Index adjustment, and a negative 0.8 percent productivity adjustment, according to the CLFS Transmittal R2823CP.

Look For New Code Payment

The CLFS prices 11 new CPT® 2014 codes, primarily new therapeutic drug assays for specific analytes. The following table shows the National Limit Amount (NLA) payment rate for the codes, all of which were priced by crosswalking the new codes to similar codes on the CLFS.

No MAAA: Although CPT® 2014 added new Multianalyte Assays with Algorithmic Analyses (MAAA) codes, you won’t see a payment amount for them on the CLFS. That’s because CMS has declined to pay for these services, instructing labs to bill the underlying lab tests instead of the MAAA code.

Wait for molecular: Because CMS determined to price molecular pathology codes by gap-fill methodology rather than crosswalking, values for new CPT® 2014 molecular codes are not yet available on the CLFS. On the other hand, last year’s gap-fill process for existing molecular codes resulted in payment values on the 2014 CLFS for 51 Tier 1 molecular pathology codes in the code range 81161-81355 and all 14 codes in the range 81370-81383 for human leukocyte antigen (HLA) typing by molecular methods. The 2014 CLFS shows no values for Tier 2 molecular pathology codes in the range 81400-81408.

Prepare for ‘Technology’ Revaluation

CMS plans to proceed with its process to reexamine payment amounts on the CLFS to take into account changes driven by technological advances. The agency defines technological changes as “changes to the tools, machines, supplies, labor, instruments, skills, techniques, and devices by which laboratory tests are produced and used.”

Under the new process, CMS will consider a list of existing codes each year for payment adjustment during the CLFS rulemaking cycle. The code selection process will involve the following steps:

• Analyze codes for high test volume, length of time on CLFS, high payment amounts, or rapid spending growth to determine which codes should be considered for a payment adjustment due to technological changes.
• If codes are identified that are clinically and/or technologically similar to the ones identified through the data analysis process, consider them for review at the same time
• Allow the public to nominate codes for review.

That’s a change: CMS originally proposed to review for revaluation all CLFS codes over the course of five years. The new process outlined in the final rule represents a step back, but not a retraction, of its technology revaluation plan.

Impact: Here’s what you can expect from the repricing exercise, according to the CLFS final rule: “Adjustments made under the new process could both increase fee schedule amounts and provide for reductions in existing amounts. We cannot estimate a net impact at this time.”

Don’t Miss Move to Bundle Lab Tests Under OPPS

CMS finalized its proposal to bundle certain pathology and clinical laboratory services into Outpatient Prospective Payment System (OPPS) groups. Prior to this policy, these lab and pathology services would be paid separately on the Physician Fee Schedule (PFS) or the CLFS.

Details: The policy will “package laboratory tests in the OPPS when they are integral, ancillary, supportive, dependent, or adjunctive to a primary service or services provided in the hospital outpatient setting; that is, when they are provided on the same date of service as the primary service and when they are ordered by the same practitioner who ordered the primary service,” according to the final rule.

This policy is part of CMS’s stated intent to make the OPPS a more complete prospective payment system and less of a fee schedule-type payment system that makes separate payment for each separately coded item, according to Charles B.

Root, PhD, president of CodeMap, a laboratory coding and reimbursement consulting company in Schaumburg, Ill.

Which codes? Appendix P of the OPPS final rule lists the bundled codes with modifier “N” (not separately payable under OPPS). The list includes most CLFS codes except 36415 (Collection of venous blood by venipuncture) and molecular pathology, as well as the following codes from the PFS:

• 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)
  
• 88185 — Flow cytometry, cell surface, cytoplasmic, or nuclear marker, technical component only; each additional marker (List separately in addition to code for first marker)
  
• 88311 — Decalcification procedure (List separately in addition to code for surgical pathology examination)
  
• 88314 — Special stain including interpretation and report; histochemical stain on frozen tissue block (List separately in addition to code for primary procedure)
  
• 88332 — Pathology consultation during surgery; each additional tissue block with frozen section(s) (List separately in addition to code for primary procedure)
  
• 88334 — Pathology consultation during surgery; cytologic examination (e.g., touch prep, squash prep), each additional site (List separately in addition to code for primary procedure).
  

Beneficiaries beware: The bundling rule could affect out-of-pocket expenses. The final rule states, “We recognize that the Medicare Part B deductible and coinsurance generally do not apply for laboratory tests paid to hospitals at CLFS rates and that the deductible and coinsurance would apply to laboratory tests packaged into other services in the OPPS.”