Pathology/Lab Coding Alert

But payment remains a mystery.

The biggest news at the annual CMS clinical laboratory Fee Schedule (CLFS) public meeting just might be what wasn't said.

Although participants were invited to propose pricing for molecular pathology codes (81200-81408) if they believed the services should be paid under the CLFS, the silence was deafening.

Interpretation: By not proposing molecular pathology payment rates at the CLFS meeting, some major industry and professional groups indicated their preference for payment on the Physician Fee Schedule (PFS).

Background: Diffusing potentially protracted debate about fee schedule placement for molecular pathology, CMS moderator Glenn McGuirk directed participants to respond to the calendar year (CY) 2013 PFS proposed rule if they had "recommendations on whether these codes represent clinical diagnostic laboratory tests that should be paid under the CLFS or services that should be paid under the PFS."

Get Up to Date on New Codes

CPT® 2012 added 101 new molecular pathology codes, but CMS declined to price the codes for CY 2012 due to "stakeholder debate whether Medicare should pay for the molecular pathology tests under the CLFS or the PFS," according to the agency.

Now CPT® proposes 13 new Tier 1 molecular pathology codes for 2013, and adds many tests to the Tier 2 list, as you can see in Table 1. With a greater number of CPT® molecular pathology codes for 2013 and the planned deletion of stacking codes (83890-83914, Molecular diagnostics ...), CMS's payment decision for molecular pathology couldn't be more crucial.

Check PFS Payment Angle

Although most presenters at the CLFS public meeting were silent on molecular pathology pricing, at least three participants stated a preference for placing the codes on the PFS based on professional work: American Society for Histocompatibility and Immunogenetics (ASHI), Association for Molecular Pathology (AMP), and College of American Pathologists (CAP).

"In contrast to the molecular pathology codes, codes on the CLFS do not require the data generated by an instrument to be interpreted by a professional prior [to it being] clinically useful data to the patient's physician," said Jonathan Myles, M.D, representing CAP.

Don't miss ramifications: Labs should be aware of coverage consequences if CMS opts to pay for molecular pathology codes on the PFS.

"For example, the technical component of molecular tests has never been subject to the 20 percent beneficiary coinsurance requirement due to payment via the CLFS; however, seniors will immediately become liable for coinsurance the moment those tests appear on the MPFS," explains Dennis Padget, MBA, CPA, FHFMA, president of DLPadget Enterprises Inc. and publisher of the Pathology Service Coding Handbook, in The Villages, Fla.

Also, payment on the PFS means that you can't bill for the molecular pathology service if a PhD clinician, rather than an M.D. or D.O., reviews and reports the test results.

Consider CLFS Payment Option

Pointing out that these aren't new tests, just new codes for existing tests, at least two meeting attendees supported continued payment for molecular pathology on the CLFS: American Clinical Laboratory Association (ACLA) and Coalition for21st Century Medicine.

"It's not an opportunity to do a wholesale reexamination of pricing for these tests -- this is basically a change of code descriptions," stated Peter Kazon, speaking on behalf of ACLA.

Recommendations for CLFS pricing included a combination of crosswalking (based on historical use of existing stacking codes) and gapfilling.

Bottom line: Based on comments from the CLFS public meeting and comments received on the (CY) 2013 PFS proposed rule, CMS intends to make a payment determination. "We want to ensure that there is a payment mechanism in place to pay for these CPT codes for CY 2013," according to the PFS proposed rule published in the July 30 Federal Register.

Resources: CLFS public meeting resources: www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/ClinicalLabFeeSched/Laboratory_Public_Meetings.html (CY) 2013 PFS proposed rule, July 30 2012 Federal Register: www.gpo.gov/fdsys/browse/collection.action?collectionCode=FR.