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Pathology/Lab Coding Alert

CPT® 2013:

81200-81479: Get Ready for Molecular Pathology Overhaul

Published on Thu Dec 06, 2012

Don't miss 'unlisted' molecular code 81479.

You had over 100 new molecular codes in 2012 that you probably never needed to use, but the safety net is gone, starting Jan. 1, 2013. That's because CPT® and CMS changes leave you no choice but to radically alter how you report these tests.

Expect to bill the appropriate CPT® 2012 or new 2013 code from the range 81200-81479 if your lab performs molecular pathology testing. Let our experts bring you up to speed on the how and why of these changes.

'Stacking' and Array Deletions Close Options

Despite having 101 new CPT® 2012 molecular pathology codes (81200-81048), most labs continued to report their tests using the "stacking codes" (83890-83914, Molecular diagnostics ...) or array codes 88384-88386 (Array-based evaluation of multiple molecular probes ...) in 2012.

That option is gone, beginning Jan. 1, because CPT® 2013 deletes 83890-83914 as well as 88384-88386. For both code groups, the deletion text note states, "To report, see 81200-81479."

Background: "Because CMS didn't price the new molecular pathology codes in 2012, labs essentially ignored the new codes and continued to bill the tests using stacking codes 83890-83914 in 2012," says Peggy Slagle, CPC, billing compliance coordinator at the University of Nebraska Medical Center in Omaha.

Similarly, the lack of new molecular code payment allowance meant that labs continued to report 88384-88386 for molecular array tests involving 11-500 probes. These tests involve devices with nucleic acid probes or DNA sequences imbedded in a platform such as a slide, chip, or microbeads, according to Diana Voorhees, MA, CLS, MT(ASCP)SH, CLCP, principal at DV & Associates Inc., in Salt Lake City.

Do this: Starting Jan. 1, you should bill molecular pathology tests using 81200-81479, regardless of methodology distinctions (such as array-based).

Substitute 81479 for 'Stack' When Billing Unlisted Tests

Deleting the stacking codes creates another problem for labs that bill certain molecular pathology tests. If your lab performs a test that doesn't fit descriptions of any Tier 1 or Tier 2 molecular test, you were to use stacking codes for the test, according to CPT® 2012.

With the deletion of those codes in 2013, you'll need to turn to another solution.

Do this: Know the hierarchy for molecular testing -- use a Tier 1 code if available, or a Tier 2 code if not. If neither a Tier 1 or Tier 2 code describes the test your lab performs, use new CPT® code 81479 (Unlisted molecular pathology procedure) instead of stacking codes starting Jan. 1.

A new note in the Tier 1 instructions states, "Molecular pathology procedures that are not specified in 81200-81383 should be reported using either the appropriate Tier 2 code (81400-81408) or the unlisted molecular pathology procedure code, 81479."

And in the Tier 2 instructions, CPT® 2013 states, "If the analyte tested is not listed under one of the Tier 2 codes or is not represented by a Tier 1 code, use the unlisted molecular pathology procedure code, 81479."

Look to CLFS for Molecular Pathology Pay

As with the deleted stacking and array codes, you can expect Medicare to pay for the new molecular pathology codes on the Clinical Laboratory Fee Schedule (CLFS).

That's in agreement with some commentators at the CLFS annual public pricing meeting for new CPT® codes, such as Peter Kazon, representing the American Clinical Laboratory Association, who pointed out, "It's not an opportunity to do a wholesale reexamination of pricing for these tests -- this is basically a change of code descriptions."

Despite other meeting commentators advocating for moving molecular pathology tests to the Medicare Physician Fee Schedule (PFS), such as Jonathan Myles, M.D, representing the College of American Pathologists (CAP), CMS announced in its final payment determination that the agency will pay for Tier 1 and Tier 2 molecular pathology tests on the CLFS using gapfill methodology for pricing.

Gapfill: CMS decided on gapfill because, "the same test is often being billed using different stacks ... [and] stacks [may] have changed over time," according to the payment determination. Unlike crosswalking a new code to the payment rate of a similar code, which allows CMS to assign a national payment amount before January when new codes become effective, gapfilling takes more time.

Here's the process CMS will follow, and the approximate timeline you can expect for pricing of gap-filled codes:

  1. Medicare contractors will develop carrier-specific gap-filled amounts by April 1 of 2013. CMS will post these on the Website and accept comments for 60 days.
  2. These amounts will then be finalized on September 30, 2013. CMS will post gap-filled payment amounts on the Website as final, and accept reconsideration requests on the gap-filled payment amounts for 30 days.
  3. Once the reconsideration process is completed for a cycle, the determination is final and would not be subject to further reconsideration

You can access CMS payment determination at www.cms.gov/ClinicalLabFeeSched/.

Stop Using Genetic Test Modifiers

... if you ever used them, that is. CPT® 2013 deletes Appendix I, including all 131 two-digit modifiers that identify specific genetic tests.

Despite the modifiers' availability for seven years, most payers and labs never adopted them, even though CPT® continued to update them with additions, according to Voorhees.

The modifiers were intended to add granularity to reporting genetic tests until a specific molecular pathology coding system could be developed. With the addition of the Tier 1 and Tier 2 molecular pathology codes, CPT® accomplishes the new system and removes the modifiers.

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