Pathology/Lab Coding Alert

Keep using 83890-83914 for most payers.

Don't expect 101 new CPT® molecular diagnostics codes to solve your specificity and payment problems -- CMS has announced that they won't price the codes for 2012.

"As Medicare goes, so go most payers," says William Dettwyler, MT-AMT, president of Codus Medicus, a laboratory coding consulting firm in Salem, Ore. Most insurers evidently plan to continue accepting the "stacking codes" (83890-83914, Molecular diagnostics; ...) in the coming year for tests they cover. "It would be best to contact your major payers before billing these tests in 2012," he says.

Read on to learn when and how you might start to use the new CPT® molecular pathology codes.

Watch for CMS Staged Implementation

CMS notes in the 2012 Medicare Physician Fee Schedule (PFS) that the AMA Relative Value Scale Update Committee (RUC) reviewed over 100 new CPT® 2012 codes describing molecular pathology services, but "they will not be valid for Medicare purposes for CY [calendar year] 2012."

The new molecular pathology codes appear in Addendum B to Medicare's PFS final rule with the procedure status indicator of I (Not valid for Medicare purposes. Medicare uses another code for the reporting and payment for these services).

Hint of things to come: CMS reps shed some light on potential future payment opportunities for molecular pathology services during the CPT® 2012 Annual Symposium in Chicago on Nov. 16. At the meeting, the agency's Marc Hartstein said that Medicare's contractors are currently pricing over 100 codes describing molecular pathology services, which are genetic tests. Although CMS decided not to price new molecular pathology codes under the current Clinical Laboratory Fee Schedule or the PFS, the agency does intend to establish payment for them in 2013, Hartstein said.

In tandem, the CPT® Editorial Committee will continue to monitor which code section(s) require revisions. The committee intends to offer special focus to molecular pathology, among other services, in 2013, said Peter A. Hollmann, MD, chair of the CPT® Editorial Panel, during the CPT® 2012 Annual Symposium.

Use 'Stacking Codes' Now

CMS says that for CY 2012, "Medicare will continue to use the current 'stacking' codes for the reporting and payment for [molecular pathology] services."

That means for Medicare and most other payers, you'll ignore the new codes and report these tests just as you have in past years.

In other words, report molecular assays using appropriate codes from the range 83890-83914. Each code describes a separate technique, such as nucleic acid extraction, gene amplification, or nucleic acid probes.

Add them up: Bill a single molecular assay by reporting each code (sometimes in multiple units) that describes each step that the lab performs. The AMA workgroup refers to these as stacking codes.

Pitfall: "The stacking code system has some problems," Dettwyler says. "Coders often have difficulty linking the highly technical test protocols to specific codes, resulting in a lack of reporting uniformity. Also, payers often deny the tests because they can't identify the genetic or cancer test."

Prepare for 'Tiers'

Even though most payers won't accept them in 2012, you need to start getting familiar with the new molecular pathology codes.

CPT® 2012 introduces 92 specific codes for commonly-used genetic markers. The remaining new molecular pathology codes describe resource-based tests not listed in the first group. These are the "Tier 1" and "Tier 2" codes, respectively.

Tier 1: These codes describe higher-volume tests such as breast cancer evaluation for BRCA1 and BRCA2, and genetic cystic fibrosis tests such as CFTR common variants. Tier 1 tests also include 14 new codes for human leukocyte antigen (HLA) typing using molecular techniques. The Tier 1 codes range from 81200 (ASPA [aspartoacylase] [e.g., Canavan disease] gene analysis, common variants [e.g., E285A, Y231X]) to 81383 (HLA Class II typing, high resolution [i.e., alleles or allele groups]; one allele or allele group [e.g., HLA-DQB1*06.02P], each).

Tier 2: For less-commonly performed molecular pathology tests, CPT® 2012 introduces resource-based codes (levels 1-9). The nine levels represent the range of technical resources and physician interpretive work required to perform a given test.

Tier 2 includes a list of specific tests under each code. For instance, level 1 (81400, Molecular pathology procedure, level 1 [e.g., identification of single germline variant (e.g., SNP) by techniques such as restriction enzyme digestion or melt curve analysis]) includes tests such as ACE (angiotensin converting enzyme) (e.g., hereditary blood pressure regulation), insertion/deletion variant.

Look ahead: Many experts express concerns that the new codes create as many problems as they solve. Look to Pathology/Lab Coding Alert for ongoing analysis and payer updates for these codes.