Proposed Coding Edits May Restrict 88305 Use

Full range of proposed edits promises bad news for both pathology groups and clinical labs

CEO SUMMARY: When the Medicare contractor tasked with developing MUEs (Medically Unbelievable Edits) for this year’s Correct Coding Initiative work released the proposed list of edits to the AMA, it didn’t take long for the bad news to reach the pathology profession. Restriction on units of service per patient are proposed for approximately 80 pathology CPTs and almost 1,100 clinical laboratory CPTs.

WORD IS FILTERING throughout the pathology profession about a proposal within the Medicare program to restrict the use of the 88305 CPT code to two units of service per patient per day.

But the bad news doesn’t stop with 88305. Proposals now under consideration by the Correct Coding Initiative (CCI) would place restrictions on the units of service for a significant number of anatomic pathology, clinical laboratory, and molecular diagnostic CPT (Current Procedural Terminology) codes.

Should the proposed restrictions on units of service for CPT 88305 (Level IV—Surgical Pathology, Gross and Microscopic Exam) eventually take effect, it would be devastating to the pathology profession. Procedures performed and coded as 88305 make up the single largest component of the anatomic pathology workload.

“I have been told by our clients, both pathologists and billing companies, that the impact of the proposed restriction of service for 88305 on the compensation of the typical pathology group practice will be between 10% and 40% of total compensation,” said Jane Pine Wood, an attorney and partner at McDonald Hopkins of Cleveland, Ohio. “The precise impact would vary, depending on the size of the Medicare population served by the pathology group and how many cases are referred by specialists, such as urologists, gastroenterologists, and dermatologists. Without question, what is proposed for this single CPT code will have an extremely negative impact.”

There is a simple reason why this news has not become widespread across the laboratory industry. These proposed CCI edits are in the earliest stages of development. They have only recently been made available for review by the various medical specialties affected, including pathology. These proposed edits have not been made public and, in fact, the distribution of this information is accompanied by confidentiality agreements.

The source of these proposals is a contractor working on behalf of the Centers for Medicare and Medicaid Services (CMS). The list of proposed pathology and laboratory CPTs to have restrictions on units of service is part of a project to develop the next round of Medically Unbelievable Edits (MUEs) for all medical specialties.

Late last year, the contractor passed the list of proposed edits to the American Medical Association (AMA). Upon receipt of this list, the AMA forwarded a copy to each medical specialty association in the United States for their review and input. This occurred in mid-December.

CAP Requests Information

Once it had evaluated the proposed edits affecting pathology, the College of American Pathologists (CAP) issued an alert concerning this matter. CAP is asking pathologists to provide input and documentation about the negative consequences that will occur if the proposed two-unit cap on 88305 were to be implemented. This information will be delivered to the AMA.

As of press time, the deadline for CAP’s comment and response to the AMA is early February. CMS is expected to implement the final list of edits in July 2006. This does not leave much time for the laboratory industry to work with the AMA and the CMS contractor to fix the more ill-conceived elements of the proposed MUEs.

“There is the potential for significant chaos between patients, referring physicians, hospitals, and pathologists,” observed Wood. “From the standpoint of medical quality, what does a hospital-based pathologist do when a surgeon sends, for example, multiple tissue specimens from a breast cancer case to the pathologist?

Serious Consequences

“The proposed restriction that limits a pathologist to filing claims for only two 88305s per patient per day will trigger serious issues of medical quality and access to care by Medicare patients,” added Wood. “It is likely that the Medicare patient will be asked to sign ABNs and personally pay for the additional 88305s. There will be greater liability exposure for both surgeon and pathologist, if the plaintiff’s bar were to believe that physicians’ actions were influenced by Medicare restrictions on service and their patient’s outcome was negatively affected.”

One big, unanswered question that surrounds the specific restrictions pro- posed for 88305 and other pathology and clinical lab CPT codes is “Why?” It is not known whether these restrictions were proposed at the direction of CMS officials, possibly to tamp down utilization—and thus reduce the amount of money Medicare pays to providers. Alternatively, it could be the result of flawed thinking by individuals working for the CMS contractor.

Expect this issue to be the regulatory “hot potato” for 2006—and that’s before the clinical laboratory segment of the industry learns about proposed service restrictions for approximately 1,100 of their CPT codes!

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