CEO SUMMARY: Consultants who work with anatomic pathologists have several theories about why Anthem is enacting deep cuts of 50% to 70% for the professional component of many anatomic pathology services. While they have different ideas about what motivates the nation’s second largest health insurer, they agree that such reductions in payments will have a
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The Current Procedural Terminology (CPT)® code set is a medical code set maintained by the American Medical Association through the CPT Editorial Panel. The CPT (copyright protected by the AMA) describes medical, surgical, and diagnostic services and is designed to communicate uniform information about medical services and procedures among physicians, coders, patients, accreditation organizations, and payers for administrative, financial, and analytical purposes.
CPT codes are a critical part of the laboratory billing process. They are similar to ICD-9 and ICD-10 coding, except that it identifies the services rendered rather than the diagnosis on the claim. CPT is currently identified by the Centers for Medicare and Medicaid Services (CMS) as Level 1 of the Healthcare Common Procedure Coding System (HCPCS).
The AMA’s CPT Editorial Panel engages in an ongoing process improvement effort that frequently includes re-examination of the CPT Category I and Category III criteria.
CPT Category I codes are the codes most used in clinical lab and pathology group billing. They are the five-digit numeric codes included in the main body of CPT. These codes represent procedures that are consistent with contemporary medical practice and are widely performed. Codes assigned to this category have met certain criteria including:
- Procedure or service approved by the Food and Drug Administration (FDA)
- Procedure or service commonly performed by health care professionals nationwide
- Procedure or service’s clinical efficacy is proven and documented
The use of the code is mandated by almost all health insurance payment and information systems, including the Centers for Medicare and Medicaid Services (CMS) and HIPAA, and the data for the code sets appears in the Federal Register.
After a clinical laboratory service is provided, diagnosis and procedure codes such as CPT codes are assigned to assist the insurance company in determining coverage and medical necessity of the services. Once the procedure and diagnosis codes are determined, the lab bill enters the laboratory collections/revenue cycle management phase.
CEO SUMMARY: Deep cuts in what Anthem pays pathologists for the professional component for certain AP services are having a harmful effect on the long-standing relationships that dermatologists have with dermatopathologists, some physicians say. By disrupting these relationships, Anthem is harming patient care, they add. Since late last year, in a growing number of states,
CEO SUMMARY: Reviewing an AP practice’s expenses is vitally important today when payers are cutting reimbursement. In the past, government and private payers paid more for the technical and professional components of anatomic pathology work, but those rates have eroded. While conversations about revenue tend to obscure the need to talk about expenses, effective financial
CEO SUMMARY: As of Aug. 1, Aetna will stop paying out-of-network pathologists for the professional component review of certain clinical pathology tests. Until now, the health insurer has paid for the professional component when out-of-network labs billed for clinical lab tests using the modifier 26. In a notice to labs, Aetna said it will pay
CEO SUMMARY: Anthem is making big changes to its relationships with anatomic pathology groups. Getting most of the attention at the moment are the insurer’s letters announcing price cuts for anatomic pathology services of 50% to 70% of Medicare fees. But another major change may also trigger negative consequences for pathologists. Anthem is moving pathology
This is a synopsis of a 2,120-word article in the July 1, 2019 issue of THE DARK REPORT (TDR). The full articles are available to members of The Dark Intelligence Group.
CEO SUMMARY: Anthem is making big changes to its relationships with anatomic pathology (AP) groups. Getting most of the attention at the moment are the
TWO OF THE NATION’S LARGER HEALTH INSURERS—AETNA AND ANTHEM— ARE CUTTING WHAT THEY PAY for the professional component of certain clinical and anatomic pathology codes.
In its communications with pathology groups about this policy change, Aetna says it will no longer pay for most clinical laboratory claims submitted with the modifier 26 for professional component services.
CEO SUMMARY: In a letter to the National Correct Coding Initiative, the American Clinical Laboratory Association (ACLA) raised significant concerns about new language in the policy manuals for Medicare and Medicaid. ACLA said the new NCCI guidelines for molecular and other tests requiring multiple steps for one specimen reduce transparency, increase the administrative burden on
CEO SUMMARY: Under guidelines the National Correct Coding Initiative issued last year, many clinical laboratories are not getting paid for some tests. The rates of denial for labs running mostly molecular tests could range from 40% to 100% of revenue, one billing expert said. Implemented Jan. 1, the guidelines apply to labs running tests in
Across the nation, clinical laboratories struggle to correctly interpret and follow the new National Correct Coding Initiative (NCCI) guidelines that took effect on Jan. 1. A financial disaster lies ahead for many labs.
“The denials are very high right now and those denials are nationwide,” stated Kyle Fetter, Executive Vice President and General Manager of Diagnostic