Pathology/Lab Coding Alert

Watch for upcoming MUE.

Now that you’re using CPT® Tier 1 and Tier 2 codes (81200-81479) to report your lab’s molecular pathology testing, you still have one roadblock to clear: how to report the physician interpretation of these test results.

You know the new go-to code is G0452 (Molecular pathology procedure; physician interpretation and report), but how to use the code has been shrouded in mystery — until now.

Watch Your Modifier

G0452 is a professional-only code, which typically means that the code wouldn’t require a technical component/professional component modifier. "Notwithstanding, G0452 appears in the Addendum B physician fee schedule for 2013 with modifier 26 (Professional component) attached, so the presumption is that Part B contractors won’t pay the code without that modifier," explains Dennis Padget, MBA, CPA, FHFMA, president of DLPadget Enterprises Inc. and publisher of the Pathology Service Coding Handbook, in The Villages, Fla.

Report G0452 per Procedure/per Specimen

The unanswered question about G0452 has been: Should you properly report it once per specimen, once per molecular test, once per day, or once per some other unit?

"We asked the CMS contractor responsible for managing the National Correct Coding Initiative (NCCI) and Medically Unlikely Edits (MUEs) — Correct Coding Solutions of Carmel, Indiana," Padget says.

The answer: "CMS allows this code [G0452-26] to be reported one time for each Tier 1 molecular pathology procedure CPT® code per distinctly identified specimen for medically reasonable and necessary physician interpretations," according to the contractor in the response to Padget. Furthermore, G0452-26 may be reported multiple times for distinct Tier 2 molecular test interpretations as well.

Prepare for MUE of 1: Although there’s currently no MUE limit for G0452, "the contractor suggests we’ll see an MUE limit of one unit for code G0452 in a forthcoming update," Padget reports. "If that goes into effect, you’ll need to report multiple units of G0452-26 for different Tier 1 or Tier 2 test interpretations on the same date of service on separate claim lines, with modifier 59 added to the second and each subsequent code."

Recap G0452 Guidelines

CMS expects you to use G0452-26 only when a physician performs a "medically necessary interpretation and written report of a molecular pathology test, above and beyond the report of laboratory results," according to CMS in the 2012 Medicare Physician Fee Schedule Final Rule.

G0452-26 is a professional-only code that CMS considers a "clinical laboratory interpretation service." As such, you’ll need to meet the following three requirements to use the code:

1. Request for interpretation by the patient’s attending physician (for hospital patient testing the request can be by standing order of the hospital’s medical staff)

2. Exercise of medical judgment by consulting physician (that is, the interpretation of a pathologist must be medically necessary)

3. Interpretation must be written in a narrative report included in the patient’s medical record.

No fee for lab scientists: CMS doesn’t provide a mechanism for lab scientists (as opposed to physicians) to bill a molecular pathology test interpretation under the new system.

According to CMS, "We do not believe it is appropriate to establish a HCPCS G-code on the CLFS for the interpretation and report of a molecular pathology test by a doctoral-level scientist or other appropriately trained nonphysician health care professional. … Payment for the interpretation and report service would be considered part of the overall CLFS payment for the molecular pathology CPT® codes."

Contrast 83912 to Win Some, Lose Some

"Prior to the deletion of CPT® molecular stacking codes, you had the option of reporting 83912-26 (Molecular diagnostics; interpretation and report, Professional component) to capture the pathologist’s interpretation," says Peggy Slagle, CPC, billing compliance coordinator at the University of Nebraska Medical Center in Omaha. Medicare paid for this service on the Physician Fee Schedule, meaning that only physicians could charge for the interpretation.

CLFS paid, too: But the Clinical Laboratory Fee Schedule also paid a (lesser) fee for 83912, billed without modifier 26. Labs billed that fee when a PhD or other appropriately-trained laboratory scientist evaluated and reported on the molecular test results. With the deletion of 83912 and its replacement with G0452, you’ll lose the ability to capture a fee for molecular pathology interpretation by a non-physician. That’s the "lose some" side of the 83912/G0452 comparison.

Bigger win: On the other hand, G0452 stacks up favorably against 83912 when comparing Medicare’s unit of service policy. By way of the NCCI Policy Manual, CMS limited you to reporting one unit of 83912 per day: "CMS interprets [83912] to include the synthesis with interpretation and report of all molecular diagnostic testing … performed on a single date of service," CMS stated. That compares to one unit of G0452 per distinct molecular pathology test per specimen.

"The policy clarification for G0452-26 unit of service is of significant benefit to pathologists and laboratories that perform molecular tests on a frequent basis," Padget says.

Example: In 2012 if you separately interpreted and reported an EGFR, ALK and KRAS molecular test on one specimen for a Medicare beneficiary, "you could bill only one unit of 83912-26 for the three tests combined; but now you’re permitted to bill three units of G0452-26 one for each different test," Padget says.