Pathology/Lab Coding Alert

You may experience short-term 'preventive care' bonus.

Now that the Supreme Court has upheld the constitutionality of portions of the Patient Protection and Affordable Care Act (ACA), you'll need to make sure your lab is ready for changes that could affect your bottom line.

Our experts have identified four topics from the law that could impact your lab.

1. Look for Preventive-Care Uptick

Based on the Supreme Court ruling, "there will continue to be a 'push' on preventive care," says Dennis Padget, MBA, CPA, FHFMA, president of DLPadget Enterprises Inc. and publisher of the Pathology Service Coding Handbook, in The Villages, Fla.

Because the ACA preventive care benefit has been in place since the law was passed, your lab may already be processing a higher volume of screening tests such as cancer screens, cholesterol evaluations, and HIV tests. The law requires both Medicare and private payers to cover the cost of preventive services, including screening tests, that the U.S. Preventive Services Task Force rates A or B.

"Millions of Americans are getting cancer screenings, mammograms and other preventive services for free thanks to the health care law," said HHS Secretary Kathleen Sebelius in a statement.

In fact, according to CMS statistics, more than 16 million Medicare beneficiaries have gotten at least one free preventive service so far in 2012 because of the ACA regulations

2. Don't Expect Fee Schedule Relief

Medicare payments are set to drop by 27 percent in 2013, unless Congress acts. Readers have asked if the Supreme Court decision changes that. The answer is "no" -- the ACA has no impact on the proposed Medicare Physician Fee Schedule, which sets payment for physician services, including pathology.

"The Sustainable Growth Rate (SGR) formula is not addressed in the ACA and is not affected by the ruling," says Barbara J. Cobuzzi, MBA, CPC, CENTC, CPC-H, CPC-P, CPC-I, CHCC, president of CRN Healthcare Solutions, a consulting firm in Tinton Falls, N.J. "Congress is expected to act to keep rates frozen for the foreseeable future. This is a political hot potato that Congress just does not want to touch."

Clinical labs beware: Some observers expect pain on the Clinical Laboratory Fee Schedule as well: "Clinical labs will see payment cutbacks, because that's a big dollar line item in the national budget," Padget says.

3. Anticipate Demise of 'Fee for Service'

How you get paid for services might see a major shift starting with ACA enactment.

"Now that the Supreme Court has ruled that the reform law is constitutional, the extensive delivery system reforms embedded in the law move forward for implementation," said Stanley J. Robboy, MD, FCAP, president of the College of American Pathologists (CAP) in a prepared statement. "The shift from volume-based fee-for-service payment to coordinated care and incentive-based reimbursement continues to gain momentum ...," he says.

You can expect to see many more restrictions as part of this shift, according to Padget, such as frequency limits (Medically Unlikely Edits), bundling restrictions (Correct Coding Initiative), coverage constraints (fewer covered ICD-9 codes), and higher penalties for failing to meet "quality measures."

4. Heed Your Own Healthcare Costs

Just like any business, you need to anticipate ACA's impact on your bottom line.

"Pathologists and labs need to be thinking about their own practices and companies too," Padget says. "Employee healthcare costs will increase significantly for them too, even if they have fewer than 50 employees."