Pathology/Lab Coding Alert

Catch a break on specimen collection fees.

Look for big changes in the Medicare Physician Fee Schedule (MPFS) 2023 final rule that will influence your lab’s pay this year.

Although the 2023 conversion factor (CF) reduction captured headlines (see Pathology/Lab Coding Alert Vol. 23 No. 12, “Brace for 2023 Physician Fee Schedule Pay Cut”), you need to know about many more MPFS changes this year.

Resource: Find the full final rule from the Centers for Medicare & Medicaid Services (CMS) at www.federalregister.gov/documents/2022/11/18/2022-23873/medicare-and-medicaid-programs-cy-2023-payment-policies-under-the-physician-fee-schedule-and-other.

Read on to see how updates to specimen collection fees, colorectal cancer (CRC) screening coverage, and lab test data collection and reporting could come home to roost in your lab’s bottom line.

Update CRC Screening Coverage Rules

CMS finalizes two changes to Medicare coverage for CRC screening in 2023 that could affect pay to pathology practices and clinical laboratories. The changes align with recent CRC screening recommendations from the United States Preventive Services Task Force (USPSTF).

First, CMS will now cover certain CRC screening tests at an earlier age. Rather than limiting coverage to beneficiaries aged 50 years or older, Medicare now covers certain CRC screening for beneficiaries as young as 45 years old.

Second, Medicare expands coverage to include a complete CRC screening, meaning that Medicare will now cover as screening, a colonoscopy indicated as medically necessary based on a positive screening lab test.

Lab impact: As a result of these changes, pathology practices may see increased utilization and coverage for examining specimens from screening colonoscopies, such as polyps. And clinical labs may see increased physician orders for screening blood or stool tests such as the following:

• 82270 (Blood, occult, by peroxidase activity (eg, guaiac), qualitative; feces, consecutive collected specimens with single determination, for colorectal neoplasm screening (ie, patient was provided 3 cards or single triple card for consecutive collection))
• G0328 (Colorectal cancer screening; fecal occult blood test, immunoassay, 1-3 simultaneous)
• 81528 (Oncology (colorectal) screening, quantitative real-time target and signal amplification of 10 DNA markers (KRAS mutations, promoter methylation of NDRG4 and BMP3) and fecal hemoglobin, utilizing stool, algorithm reported as a positive or negative result)
• G0327 (Colorectal cancer screening; blood-based biomarker)

Patient impact: Under these 2023 MPFS changes, cost sharing will not apply for either the initial stool-based test or the follow-up colonoscopy.

Social impact: These two changes reflect CMS goals to expand access to quality care and to improve health outcomes for patients through prevention and early detection service. “The Biden-Harris Administration is committed to expanding access to vital prevention and treatment services,” explains HHS Secretary Xavier Becerra in a release addressing the 2023 MPFS.

“Access to services promoting behavioral health, wellness, and whole-person care is key to helping people achieve the best health possible,” says CMS Administrator Chiquita Brooks-LaSure in the release.

Claim Increased Specimen Collection Pay

As of January 1, your lab can charge a specimen collection fee of $8.57 for specimen collection from a homebound or non-hospital inpatient Medicare patient encounter, or $10.57 for specimens collected at a Skilled Nursing Facility (SNF) or Home Health Agency (HHA). That’s a substantial increase from the prior $3 or $5 allowances.

Restrictions: Medicare requires that your lab meet the following requirements to be eligible for the specimen collection fees:

• The test is a medically necessary clinical diagnostic laboratory test (CDLT) paid on the Clinical Laboratory Fee Schedule (CLFS);
• You may charge one specimen collection fee per patient encounter no matter how many specimens you acquire;
• No qualified personnel are available at the facility to collect the specimen;
• A trained technician (including phlebotomist) collects the specimen; and
• The specimen is a blood sample collected using venipuncture or a urine sample collected by catheterization.

You must use one of the following codes to report the specimen collection service:

• 36415 (Collection of venous blood by venipuncture)
• G0471 (Collection of venous blood by venipuncture or urine sample by catheterization from an individual in a skilled nursing facility (SNF) or by a laboratory on behalf of a home health agency (HHA))
• P9612 (Catheterization for collection of specimen, single patient, all places of service)
• P9615 (Catheterization for collection of specimen(s) (multiple patients))

Expect updates: Not only does the specimen collection fee increase dramatically for 2023, but the final rule states that pricing adjustments will occur each year based on the percent change in the urban consumer price index (CPI-U) for the 12 month period ending June 30 of the preceding year.

Clear up Travel Allowance Pay

The final MPFS also outlines changes to the Medicare travel allowance policy for specimen collection. You can charge for travel only if you can bill for the technician to collect a specimen. That means you need to meet the criteria mentioned in the previous section.

Key: You can’t charge a travel allowance for a messenger to pick up a specimen.

If you meet the criteria for charging a travel allowance, the amount you bill will depend on the distance traveled and the number of eligible (and ineligible) stops.

Eligible miles: You should count the miles traveled beginning at the laboratory or the starting point of the technician’s travel for a qualifying specimen collection, and ending at the laboratory or the technician’s ending point. If the technician makes stops for non-Medicare beneficiaries or for personal reasons, those miles should be excluded from the calculation.

Two tier: Medicare establishes the following two-tiered structure for the travel allowance:

• Flat rate: Use this when the trained technician travels 20 or fewer eligible miles to collect specimens for one or more beneficiaries at a single location. The rate is $10.40 divided by the number of Medicare beneficiaries.
• Per mile: Use this when the trained technician travels more than 20 eligible miles to a single location for one or more beneficiary collections, or they travel to more than one location to collect specimens from more than one beneficiary. The rate is $1.04 per mile multiplied by the number of eligible miles, divided by the number of Medicare beneficiaries served.

Update Lab Reporting and Payment Expectations

Following COVID-19 pandemic disruption in clinical lab test reporting and payment changes mandated by the Protecting Access to Medicare Act (PAMA), CMS finalizes two items in the 2023 MPFS.

Recall: PAMA requires applicable laboratories to report to Medicare on a prescribed schedule, data on test usage and payment from commercial payers, which Medicare then uses to set the CLFS rates. The second reporting period was delayed due to the COVID-19 public health emergency (PHE).

Now the 2023 MPFS states that data reporting period required for January 1, 2023 through March 31, 2023 will use data collected January 1, 2019 through June 30, 2019. CMS also clarifies that data reporting is required every three years beginning January 2023.

CMS also established in the final rule that CLFS payment rates for 2023 through 2025 may not be reduced by more than 15 percent of the rate of the preceding year.

CYs 2023 through 2025, payment may not be reduced by more than 15 percent as compared to the amount established for the preceding year.