Pathology/Lab Coding Alert

Look ahead to a new way of coding molecular tests.

Molecular assay reporting will never be the same when the labors of an AMA CPT® Editorial Panel workgroup come to fruition next year. Let's take a sneak peak toward CPT® 2012 to help you prepare for what promises to be a complete molecular coding overhaul.

Don't miss: The changes will apply to molecular assays in "cancer, genetics and histocompatibility," but not "molecular microbiology tests or most cytogenetic assays," according to the workgroup report available at www.ama-assn.org/resources/doc/cpt/request-for-molecular-pathology-code-review-andfeedback.pdf.

Now You 'Stack' Each Step

Currently, labs report molecular assays using appropriate codes from the range 83890-83914 (Molecular diagnostics; ...). Each code describes a separate technique, such as nucleic acid extraction, gene amplification, or nucleic acid probes.

Add them up: Labs 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: "This present stacking code system has lots of problems," says William Dettwyler, MT AMT, president of Codus Medicus, a laboratory coding consulting firm in Salem, Ore. "Coders often aren't able to link the highly technical test protocols to specific codes, resulting in a lack of reporting uniformity. Also, based on the test codes billed, payers often can't identify the genetic or cancer test, so labs can get caught in a non-payment situation with no advance beneficiary notification (ABN) on file to allow them to bill the patient."

Prepare for Specific 'Tier 1' Codes

The current proposal for 2012 would include nearly 80 new, analyte-specific CPT® codes for the most commonly-performed molecular assays. These are "Tier 1" codes that include tests such as breast cancer evaluation for BRCA1 and BRCA2, and genetic cystic fibrosis tests such as CFTR common variants. The new CPT® code numbers are not yet available.

CPT® 2012 Tier 1 tests will also include 14 new codes for human leukocyte antigen (HLA) typing using molecular techniques.

Identify Resource Use for 'Tier 2'

For less-commonly performed tests, you'll have nine resourcelevel codes in 2012 to describe specific tests. The nine levels represent the range of technical resources and physician interpretive work required to perform a given test.

CPT® 2012 will include a list of specific tests under each code. For instance, level 1 will include F2 (coagulation factor2) (e.g., hereditary hypercoagul ability), 1199G>A variant while level 2 will include HTT (Huntington) (e.g., Huntington disease), evaluation to detect abnormal (e.g., expanded) alleles.

Not Listed? Stay the Course

For a molecular assay not listed as a Tier 1 or Tier 2 code for 2012, labs will be instructed to continue to report the appropriate methodology codes in the 83890-83914 range.

Remember: "You'll have to use the most specific code available in 2012," Dettwyler cautions. "You shouldn't continue to report 83890-83914 codes if CPT® lists your test using a Tier 1 or Tier 2 code. "

Watch for phase out: The workgroup states the intention to retire the stacking codes (83890-83914) "at the conclusion of this initiative (most likely 2013)."

Address Multiple Tests and Other Questions

Despite the fact that the workgroup intends for the proposed codes to provide "solutions to issues for coding molecular assays," the current proposal leaves many unanswered questions.

Can you bill multiple tests? Presumably labs will be able to separately bill multiple unique molecular tests for the same patient using multiple new codes, but the proposal doesn't specifically state that fact, potentially leaving the tests open to payer bundling issues.

How should you bill quantitative tests? The proposed codes describe qualitative analyses "unless otherwise noted," according to the workgroup. "Labs will need instruction regarding how to code any molecular pathology test that's quantitative or semi-quantitative," says Dennis Padget, MBA, CPA, FHFMA, president of DLPadget Enterprises Inc. and publisher of the Pathology Service Coding Handbook, in The Villages, Fla.

What about interpretation? The proposal includes several ambiguities about interpretation services for the proposed codes. For instance, the proposal states that when you perform only the interpretation and report, you should append modifier 26 (Professional component) to the molecular pathology code. But this only works within the Medicare payment structure if the codes appear on the clinical lab fee schedule and again on the physician fee schedule with modifier 26 -- and that arrangement creates billing and payment problems when a reference-lab pathologist performs the interpretation.

"Close coordination with Medicare and the major private insurers is going to be critical to the success of the proposed new molecular pathology coding approach," Padget cautions. "For example, Medicare beneficiary coinsurance liability and ease of pathologist interpretation payment are two considerations that will be dramatically impacted by the decision to place the new codes on the clinical lab fee schedule, the physician fee schedule, or both. Frankly, the proposed coding approach could end up being more problematic than the  'stacking code' approach if payers don't get on board with the requisite payment rate and coverage changes it demands."