Pathology/Lab Coding Alert

Drug screen reconsideration tops commentators' concerns.

If your lab runs a single-result test for HIV-1 antigens and HIV-1/HIV-2 antibodies, you'll have a new code to report the service in 2012. That's one of just two new CPT® 2012 codes that debuted at the annual CMS laboratory public meeting for pricing new test codes for payment on the clinical laboratory fee schedule (CLFS).

Bigger news: With five codes on CMS's "reconsideration request" list, this year's meeting featured much discussion about drug test coding despite no new code on the horizon.

Match Newer Methods to New Codes

Expect the following two new clinical lab test codes in CPT® 2012 (final numbering to be determined):

• 863XX -- Nuclear Matrix Protein 22 (NMP22), qualitative
• 873XX -- HIV-1 antigen(s), with HIV-1 and HIV-2 antibodies, single result

Both codes provide more specific reporting for newer tests you may have recently added to your menu.

For instance: Code 873XX describes a "fourth generation test" that represents a method labs can perform on "a variety of platforms," according to Vickie Baselski, PhD, department of pathology, University of Tennessee Health Science Center in Memphis representing the American Society for Microbiology at the CMS public meeting.

The new point-of-care NMP22 (863XX) test looks for protein in the urine that is elevated during cell death for a person who has bladder cancer, according to Gregory Lips, representing Alere Medical at the CMS public meeting.

Drug Testing Leads 'Reconsideration' Concerns

In addition to pricing recommendations for the new codes, CMS heard public comments for reconsideration requests for the following 2011 codes:

• G0434 -- Drug screen, other than chromatographic; any number of drug classes, by CLIA waived test or moderate complexity test, per patient encounter
• G0435 -- Infectious agent antigen detection by rapid antibody test of oral mucosa transudate, HIV-1 or HIV-2, screening
• 83861 -- Microfluidic analysis utilizing an integrated collection and analysis device; tear osmolarity
• 86481 -- Tuberculosis test, cell mediated immunity antigen response measurement; enumeration of gamma-interferon producing T-cells in cell suspension
• 87906 -- Infectious agent genotype analysis by nucleic acid (DNA or RNA); HIV-1, other region (e.g., integrase, fusion)

Drug screen: Several commentators suggested changing G0434 to include only CLIA waived tests, while introducing a new code for moderate complexity tests priced at four times G0434. The current grouping under G0434 penalizes clinical labs that perform these tests using instrumented moderate complexity systems, according to Paul Radensky, representing McDermott Will & Emery LLP at the CMS public meeting. The moderate complexity instruments provide some clinical advantages, such as higher specificity, that commentators said should not be discouraged by coding and reimbursement.

Comment on Pricing Proposal by October

CMS received industry input during the July 18, 2011, public meeting for the new codes. You can find CMS's proposed payments at www.cms.gov/ClinicalLabFeeSched/ by early September, and you can make comments on the recommended pricing. CMS will post final payment determinations on the same Website in Oct. 2011, according to CMS contact Glenn McGuirk.

Expect crosswalk: Although payment method for codes can be either crosswalk (paying at the same rate as a comparable existing code) or gap-fill (pricing a code based on analysis of annual carrier payment rates), almost all presenters at the public meeting recommended crosswalks for the new codes.

Where's the Molecular Diagnostics?

Although the AMA has proposed 101 new CPT® 2012 codes for molecular assays in cancer, genetics and histocompatibility, CMS won't consider setting prices for those codes on the CLFS next year, because they weren't under consideration at the public meeting.

Which fee schedule? CMS held a separate July 18, 2011 information session on the new molecular diagnostics codes. A primary question was whether CMS should price the codes on the CLFS or the Physician Fee Schedule (PFS).

Code introduction: You can read about the 2012 molecular diagnostics code changes in "83890-83914: Planned Obsolescence Brings Host of New Codes," Pathology/Lab Coding Alert Vol. 12. No. 6. Watch upcoming issues for more on these codes.