Molecular Code Stacks Now in the Payers’ Bull’s Eye

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LIKE A STEAM BOILER READY TO EXPLODE FROM TOO MUCH PRESSURE, the nation’s health insurers have reached a point of no return on the subject of code-stacked claims for genetic testing and molecular diagnostics assays. Simply put, payers are ready to tackle this sensitive issue.

Payers have reasonable questions about this type of clinical lab testing. Is it sound practice to accept a claim for a laboratory test that does not identify the clinical function of the diagnostic test? Equally relevant, why would labs expect any payer to reimburse a laboratory test claim that didn’t include information necessary to identify that the molecular lab test is an appropriate clinical procedure for the patient, given the specific health conditions the attending physician is investigating?

Code stacking claims for genetic tests and molecular assays generally fail to give payers useful information on both of these points. If this were your company, and you were paying the bills, would you consider it good business to accept these claims without challenge and issue payment? Wouldn’t you want to understand the clinical purpose and the clinical efficacy of these genetic and molecular tests?

How did health insurers and the clinical lab testing industry get to this point? The process of creating new CPT codes probably has a role in this story. After all, we are more than a decade into the genetic testing era and the CPT coding system is woefully behind today’s molecular testing marketplace.

Most pathologists have heard the comment attributed to Otto von Bismarck, a German politician of the 19th Century, who said: “If you like laws and sausages, you should never watch either one being made.” Some have hinted that the process and politics of updating the CPT coding system would probably fit Bismarck’s description of law- and sausage-making.

The fact remains that current CPT codes do not help labs describe all the tests they perform in support of clinical care. Nor do health insurers get the precise information they need when code-stacked claims for molecular tests are submitted for reimbursement. It is no surprise, then, that, as of March 1, 2012, one important Medicare carrier is stepping up with a plan to provide an interim solution to the recognized inadequacies of existing CPT codes for genetic and molecular tests. It may not be perfect, and it is likely to be criticized and even challenged in court. But it is the shoe that everyone has been waiting to drop. And now it appears that it will.

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