Pathology/Lab Coding Alert

CMS recently previewed new codes and new pricing that may affect your bottom line. Lab groups advised pricing for six new Clinical Laboratory Fee Schedule (CLFS) CPT codes at a July CMS meeting. And in August, CMS published the proposed Physician Fee Schedule for 2004. Both fee schedules will be effective Jan.1, 2004.

Labs Advocate Crosswalking New Codes

Six new CPT codes were the topic of CMS' July 28 annual public meeting for CLFS pricing. (See the new and modified codes in the table on page 79, "CPT 2004 for Clinical Lab Fee Schedule.") Lab groups unanimously supported "crosswalking" the new codes - pricing a new code the same as an existing, similar code - although code recommendations varied. The alternative pricing method involves "gap-filling," which allows individual carriers to set rates for a year before evaluating the data to set national limitation amounts.

The College of American Pathologists (CAP), represented by Stephen N. Bauer, MD, FCAP, recommended crosswalking new codes to existing codes within the same family: 8415x to 84155, 8726x to 87272, 8732x to 87328, and 8766x to 87470. Most other lab groups agreed with these recommendations.

The most controversial code pricing involved 8505x (Reticulated platelet assay), which CAP advised crosswalking to 86361 (T cells; absolute CD4 count) less the cost of the CD4 antibody flow reagent. Other groups recommended crosswalking to the technical component of 88180 (Flow cytometry; each cell surface, cytoplasmic or nuclear marker), paid under the Physician Fee Schedule rather than CLFS.

Watch for 2004 Physician Fee Schedule Changes

In its proposed fee schedule published in the August 15 Federal Register, CMS projected a -4.2 percent payment adjustment for 2004. Pathologists could be in for better news, however, says Tom Scully, CMS administrator, who pointed out that "While CMS is required to publish a proposed Physician Fee Schedule rule at this time, both the House and Senate versions of Medicare legislation contain provisions that address the proposed fee schedule cuts."

CMS also said that pathologists should look for changes to flow cytometry coding. The current code, 88180, includes both a technical and professional component. But according to CMS, pathologists should not bill the professional component (modifier -26, Professional component) if the treating physician interprets the test based on both lab results and other clinical factors, as often happens in HIV monitoring.

And, CMS says that if the pathologist does interpret 88180 test results in situations such as diagnosis of lymphoma or leukemia, "there is a single interpretation based on the quantification of all markers tested, ... not ... each marker individually," despite the fact that you use 88180-TC (Technical component) for each marker. Look for 88180 coding changes in the final fee schedule, because CMS concludes that the professional component of 88180 does not reflect current flow cytometry practice.

CPT 2004 for Clinical Lab Fee Schedule

Once again CMS let us preview new CPT codes for the coming year that it will pay under the Clinical Laboratory Fee Schedule. The third annual meeting for laboratory pricing comments, held July 28, revealed the  code changes that we'll see in 2004 are in the chart in this article.