CLMA audioLab
November 29, 2010
Diana W. Voorhees, M.A.
CLS, MT, SH, CLCP
Principal/CEO
DV & Associates, Inc.
dvassoc@aol.com
801.272.3672
Discuss Coding Changes for 2011
including CPT, HCPCS, and ICD-9
 Describe latest changes to CCI
 Indicate projected reimbursement for
2011
 Discuss pertinent policies and issues
affecting laboratory and pathology
billing and reimbursement

DV & Associates, Inc.
3
New codes reimbursed under the CLFS
and MPFS
 Recommendations under CLFS are
crosswalk or gapfill
 Reconsideration requests for 5 codes
 Include deletions and description
changes

DV & Associates, Inc.
4

HCPCS G0430 Drug screen,
qualitative; multiple drug classes
other than chromatographic method,
each procedure
◦ No comments
◦ Scheduled for deletion
DV & Associates, Inc.
5

HCPCS G0431
Drug screen, qualitative;
single drug class method (e.g., immunoassay,
enzyme assay), each drug class
◦ No comments
◦ Providers requesting an examination of payment
levels for the two “G” codes
◦ Is it fair to reimburse “kits” the same amount
regardless of the number of classes tested?
◦ 80101 not likely to be recognized again by
Medicare
◦ Code G0431 apply only to CLIA high complexity
laboratories; G0430x5 = $104.15
DV & Associates, Inc.
6

CPT 80104
Drug screen, qualitative;
multiple drug classes other
than chromatographic method,
each procedure
◦ This code takes the place of G0430
◦ One organization suggested CPT 80101
($19.72) and three others suggested
G0430 ($20.83)
◦ Apply to CLIA regulated facilities only?
DV & Associates, Inc.
7

HCPCS GXXX1 Drug screen, other
than chromatographic; any number of
drug classes, per specimen
◦ No recommendations detected
◦ Use for CLIA waived testing
◦ Xwalk to G0430 and $20.83
DV & Associates, Inc.
8

CPT 82930 Gastric acid analysis,
includes pH if performed, each
specimen
◦ Four organizations recommended CPT
82928 ($9.38)
DV & Associates, Inc.
9
82926 Gastric acid, free and total,
each specimen
 82928 Gastric acid, free or total, each
specimen

DV & Associates, Inc.
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
CPT 83861
Microfluidic analysis utilizing
an integrated collection and
analysis device, tear
osmolarity
◦ One organization recommended a gapfill, based on
the manufacturer’s costing analysis
◦ Xwalk to 83909 and $24
◦ Sets the scene for coding other procedures using
similar devices and thus the outcome can be
significant
◦ New parenthetical comment indicates code is per
eye; If both eyes, report twice
DV & Associates, Inc.
11

CPT 84112
Placental alpha microglobulin-1
(PAMG-1), cervicovaginal
secretion, qualitative
◦ Five organizations recommended CPT 82731 (fetal
fibronectin ($92.26))
◦ Amnisure Rupture Of Membranes (ROM) test
◦ Rapid, no instrument, qualitative, monoclonal
antibodies
◦ Immunochromatographic in vitro detection of the
protein PAMG-1
◦ Present in cervico-vaginal discharge following rupture
of the [fetal] membranes
◦ Identify preterm labor
DV & Associates, Inc.
12

CPT 85598
Phospholipid
neutralization; hexagonal
phospholipid
◦ Three organizations recommended CPT
85597 (platelet neutralization ($25.75))
◦ Confirmatory test for Lupus
anticoagulants
DV & Associates, Inc.
13

85597
Platelet Phospholipid
neutralization; platelet
DV & Associates, Inc.
14

CPT 86481
Tuberculosis test, cell mediated
immunity antigen response measurement;
enumeration of gamma interferon-producing
T-cells in cell suspension
◦ Four organizations recommended CPT 86480
(Tuberculosis test, cell mediated immunity
measurement of gamma interferon antigen
response ($88.77) and the other recommended
CPT 86480 + 86359 (total T cells) ($142.80 total)
DV & Associates, Inc.
15

86480
Tuberculosis test, cell
mediated immunity antigen response
measurement; of gamma interferon
antigen response
DV & Associates, Inc.
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
CPT 86902
Blood typing; antigen testing of
donor blood using reagent serum, each
antigen test
◦ Four organizations recommended CPT 86903
(Blood typing; antigen screening for compatible
blood unit using reagent serum, per unit screened
($13.52))
◦ New parenthetical comment indicates if multiple
blood units are tested for the same antigen, code
should be reported for each antigen for each unit
tested
DV & Associates, Inc.
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
86903 Blood typing; antigen
screening for compatible blood
unit using reagent serum, per
unit screened
DV & Associates, Inc.
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
CPT 87501 Infectious agent detection
by nucleic acid (DNA or RNA);
influenza virus, reverse transcription
and amplified probe technique, each
type or subtype
◦ Three organizations recommended CPT
87798 (NOS ($50.27)) + 83902 (RT)
($70.60 total)
DV & Associates, Inc.
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
CPT 87502
Infectious agent detection by
nucleic acid (DNA or RNA); influenza virus, for
multiple types or sub-types, reverse
transcription and amplified probe technique,
first 2 types or sub-types
◦ One organization recommended CPT 87798x2 and
83902x2 ($217.20)
◦ Four organizations recommended CPT 87801
(multiple organisms PCR ($100.54)) + 83902
($120.87 total)
DV & Associates, Inc.
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
CPT +87503 Infectious agent detection by
nucleic acid (DNA or RNA); influenza virus, for
multiple types or sub-types, multiplex
reverse transcription and amplified probe
technique, each additional influenza virus
type or sub-type beyond 2 (List separately in
addition to code for primary procedure)
◦ Note add on code
◦ One organization recommended CPT 87798 +
83902 ($70.60)
◦ Three organizations recommended CPT 83901 +
83896 ($29.75)
DV & Associates, Inc.
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
CPT 87906 Infectious agent genotype
analysis by nucleic acid (DNA or RNA);
HIV-1, other region (eg, integrase,
fusion)
◦ Five organizations recommended CPT
87901 (genotype, nucleic acid, HIV-1, RT
and protease ($368.73))
DV & Associates, Inc.
22

87901 Infectious agent genotype
analysis by nucleic acid (DNA
or RNA); HIV-1, reverse
transcriptase and protease
regions
DV & Associates, Inc.
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
HCPCS G0432 Infectious agent
antibody detection by enzyme
immunoassay (EIA) technique, HIV-1
and/or HIV-2, screening
◦ Four organizations recommended CPT
86702 (Antibody, HIV-1 and HIV-2, single
assay ($19.65)
DV & Associates, Inc.
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
HCPCS G0433 Infectious agent
antibody detection by enzyme-linked
immunosorbent assay (ELISA)
technique, HIV-1 and/or HIV-2,
screening
◦ Four organizations recommended CPT
86702 (Antibody, HIV-1 and HIV-2, single
assay ($19.65)
DV & Associates, Inc.
25

HCPCS G0435 Infectious agent
antibody detection by rapid antibody
test, HIV-1 and/or HIV-2, screening
◦ Four organizations recommended CPT
86702 (Antibody, HIV-1 and HIV-2, single
assay ($19.65)
DV & Associates, Inc.
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
CPT 88749 Unlisted in vivo (eg,
transcutaneous)
laboratory service
DV & Associates, Inc.
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
+82952
Glucose; tolerance test,
each additional beyond 3 specimens
(List separately in addition to code for
primary procedure)
◦ Note add on code
DV & Associates, Inc.
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
CPT 84145 Procalcitonin (PCT)
◦ No discussion detected
◦ CLFS NLA $27.76
◦ Xwalk to calcitonin (82308) and $38.36
DV & Associates, Inc.
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
CPT 84431 Thromboxane
metabolite(s), including thromboxane
if performed, urine
◦ No discussion detected
◦ CLFS NLA $18.54
◦ Creatinine may also be billed $7.41
◦ Xwalk to TSH and $24.06
DV & Associates, Inc.
30

CPT 86352
Cellular function assay
involving stimulation (e.g., mitogen or
antigen) and detection of biomarker (e.g.,
ATP)
◦ Two organizations recommended gapfill
◦ Obtain costing information
◦ Xwalk to phytomitogen (86353x2) +
chemilluminescence (82397x2) = $180.92
DV & Associates, Inc.
31

89100

89105
Duodenal intubation and aspiration;
single specimen (eg, simple bile
study or afferent loop culture) plus
appropriate test procedure
collection of multiple fractional
specimens with pancreatic or
gallbladder stimulation, single
or double lumen tube
DV & Associates, Inc.
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
89130

89132
Gastric intubation and aspiration,
diagnostic, each specimen, for
chemical analyses or cytopathology;
after stimulation
DV & Associates, Inc.
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
89135

89136
89140

89141

Gastric intubation, aspiration, and
fractional collections (eg, gastric
secretory study); 1 hour
2 hours
2 hours including gastric
stimulation (eg, histalog,
pentagastrin)
3 hours, including gastric
stimulation
DV & Associates, Inc.
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

89225
89235
Starch granules, feces
Water load test
DV & Associates, Inc.
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

88120 Cytopathology, in situ
hybridization (eg, FISH), urinary
tract specimen with morphometric
analysis, 3-5 molecular probes,
each specimen; manual
88121 Cytopathology, in situ
hybridization (eg, FISH), urinary
tract specimen with morphometric
analysis, 3-5 molecular probes,
each specimen; using computerassisted technology
DV & Associates, Inc.
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
CPT 88120 and 88121, Cont.
◦ Parenthetical comments that morphometric FISH on
non-urinary cytologic specimens apply to 88367
and 88368
◦ More than 5 probes should be coded with CPT
88399
◦ Parenthetical comment following CPT 88368 refers
evaluation of urinary tract specimens to CPT 88120
or 88121
DV & Associates, Inc.
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
88172 Cytopathology, evaluation of fine
needle aspirate; immediate cytohistologic
study to determine adequacy of specimen(s)
for diagnosis, first evaluation episode, each
site
◦ New parenthetical comment that an episode is a
complete set of cytologic material submitted for
evaluation and is independent of the number of
needle passes or slides prepared. Separate episode
occurs if the proceduralist obtains additional
material from the same site based on the prior
immediate evaluation or a separate lesion is
aspirated
DV & Associates, Inc.
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
CPT +88177
Cytopathology, evaluation of
fine needle aspirate;
immediate cytohistologic study to determine
adequacy for diagnosis, each separate
additional evaluation episode, same site (List
separately in addition to code for primary
procedure)
◦ Note an add on code
◦ Resequenced
DV & Associates, Inc.
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
CPT +88177, Cont.
◦ Parenthetical comment indicates the code
is used when repeat evaluation episode(s)
is required on subsequent cytologic
material from the same site
 Prior sampling not adequate
DV & Associates, Inc.
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
88363 Examination and selection of
retrieved archival (ie, previously
diagnosed) tissue(s) for
molecular analysis (eg, KRAS
mutational analysis)
DV & Associates, Inc.
◦ Review of archived sample to select blocks most
appropriate for molecular study
◦ Does not include microdissection or molecular
interpretation
41

HCPCS G9143 Pharmacogenomic
testing for Warfarin response
◦ No recommendations detected
◦ Xwalk to 83891 + 83896x3 + 83900 +
83901 + 83908x3 + 83912 = $172.76
DV & Associates, Inc.
42


+88332
Pathology consultation during
surgery; each additional tissue block with
frozen section(s) (List separately in addition
to code for primary procedure)
◦ Note add on code
◦ Use with CPT 88331
+88334
cytologic examination (eg, touch
prep, squash prep), each additional site (List
separately in addition to code for primary
procedure)
Note add on code;
Use CPT 88334 with 88331, 88333
DV & Associates, Inc.
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
Molecular Modifiers
◦ ▲4A HLA-A*
◦ ▲4B HLA-B*
◦ ▲4C HLA-C*
◦ (Modifier 4D has been deleted) HLA D
◦ ▲4E HLA-DRB all
◦ # ●4P HLA-DRB1*
◦ # ●4Q HLA-DRB3*
DV & Associates, Inc.
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
Molecular Modifiers
HLA-DRB4*
HLA-DRB5*
HLA-DQA1*
HLA-DQB1*
HLA-DPA1*
HLA-DPB1*
Histocompatiblity/typing, not
otherwise specified
DV & Associates, Inc.
◦ # ●4R
◦ # ●4S
◦ ●4T
◦ ▲4F
◦ #● 4U
◦ ▲4G
◦ ▲4Z
45

Genetic Modifiers Renumbering
DV & Associates, Inc.
◦ # 4P Modifier is out of numerical
sequence. See Modifier
4A-4Z
◦ # 4Q Modifier is out of numerical
sequence. See Modifier
4A-4Z
◦ # 4R Modifier is out of numerical
sequence. See Modifier
4A-4Z
46

Molecular Modifiers
DV & Associates, Inc.
◦ # 4S Modifier is out of numerical
sequence. See Modifier 4A-4Z
◦ # 4T Modifier is out of numerical
sequence. See Modifier 4A-4Z
◦ # 4U Modifier is out of numerical
sequence. See Modifier 4A-4Z
47




287.4
Secondary thrombocytopenia
Add
287.41 Post-transfusion purpura
287.49 Other secondary thrombocytopenia
DV & Associates, Inc.
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


780.6
Fever and other physiologic
disturbances of temperature
regulation
Add
780.66 Febrile nonhemolytic transfusion
reaction
DV & Associates, Inc.
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



276.6
Fluid overload
Add:
276.61 Transfusion associated circulatory
overload
276.69 Other fluid overload
DV & Associates, Inc.
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
275.0
Disorders of iron metabolism
◦ Invalid and replace it with the following:




275.01 Hereditary hemochromatosis
275.02 Hemochromatosis due to
repeated red blood cell
transfusions
275.09 Other disorders of iron
metabolism
275.03 Other hemochromatosis
DV & Associates, Inc.
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
488.0

488.1

Add
488.01

488.02

Influenza due to identified avian
influenza virus
Influenza due to identified novel
H1N1 influenza virus
Influenza due to identified avian
influenza virus with pneumonia
Influenza due to identified avian
influenza virus with other
respiratory manifestations
DV & Associates, Inc.
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◦ 488.09
◦ 488.11
◦ 488.12
◦ 488.19
Influenza due to identified avian
influenza virus with other
manifestations
Influenza due to identified novel
H1N1 influenza virus with
pneumonia
Influenza due to identified novel
H1N1 influenza virus with other
respiratory manifestations
Influenza due to identified novel
H1N1 influenza virus with other
manifestations
DV & Associates, Inc.
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
Numerous transfusion code changes
◦ Deletions
◦ Additions

Examples: Invalid
◦ 999.6
◦ 999.7
ABO incompatibility reaction
Rh incompatibility reaction
DV & Associates, Inc.
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
Examples: Added
◦ 999.62 ABO incompatibility with acute hemolytic
transfusion reaction
◦ 999.63 ABO incompatibility with delayed
hemolytic transfusion reaction
◦ 999.71 Rh incompatibility with hemolytic
transfusion reaction not specified as acute
or delayed
◦ 999.72 Rh incompatibility with acute hemolytic
transfusion reaction
◦ 999.85 Delayed hemolytic transfusion reaction,
incompatibility unspecified
DV & Associates, Inc.
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


CPT 88312, 88313, 88342, 88360 & 88361
The unit of service for special stains is each
stain
“If it is medically reasonable and necessary
to perform the same stain on more than
one specimen or more than one block of
tissue from the same specimen, additional
units of service may be reported for the
additional specimen(s) or block(s).”
DV & Associates, Inc.
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
“Physicians should not report more than one
unit of service for a stain performed on a single
tissue block. For example it is common
practice to cut multiple levels from a tissue
block and stain each level with the same stain.
The multiple levels from the same block of
tissue stained with the same stain should not
be reported as additional units of service. Only
one unit of service should be reported for the
stain on multiple levels from the single tissue
block.”
DV & Associates, Inc.
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

Clarity in use of stains and UOS
“Physicians should not report more than one
unit of service for a stain performed on a
single tissue block. For example it is common
practice to cut multiple levels from a tissue
block and stain each level with the same
stain. The multiple levels from the same
block of tissue stained with the same stain
should not be reported as additional units of
service. “
DV & Associates, Inc.
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


Stains, Cont.
“Only one unit of service should be reported
for the stain on multiple levels from the
single tissue block.”
“For cytology specimens from a single
anatomic site only one unit of service may be
reported for each special stain regardless of
the number of slides from that site stained
with the special stain.”
DV & Associates, Inc.
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

“Additionally, controls performed with special
stains should not be reported as separate
units of service for the stain.”
Use caution and document staining exercise
DV & Associates, Inc.
60

CPT Assistant , October 2010

Question
◦ We received two blocks, both labeled ABC09-1234
(C & D). We performed CD20 and CD45 on both
blocks. Would we code this scenario as 88342 x2
or x4?

Response
◦ CPT 88342, each antibody, should be reported
twice. It is “each antibody” no matter how many
blocks are applied to a given specimen
DV & Associates, Inc.
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


Transmittal R1921CP, 2/19/10
Voluntary versus mandatory ABN
NEMB blended into ABN
◦ Advanced Beneficiary Notice of Noncoverage
(ABN)


Effective Date: April 1, 2010
Implementation Date: April 5, 2010
DV & Associates, Inc.
62

GA
Waiver of liability statement issued
as required by payer policy
◦ Mandatory use
◦ Submitted with covered charges
◦ Medicare will now deny these claims as a
beneficiary liability (CO-50)
◦ No medical review
◦ Beneficiary have the right to appeal
◦ Changed September 17, effective last April 1,
Transmittal 770
 Suspension of automatic denial with -GA
DV & Associates, Inc.
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
July 15, 2009 Bureau of Labor
Statistics
◦ Consumer Price Index (urban) = -1.4%

Less 0.5%
◦ Medicare Improvement for Patients and
Providers Act (MIPPA)
 0.5% below the CPI for urban consumers
through 2013

Overall adjustment -1.9%
◦ First negative adjustment
DV & Associates, Inc.
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
June 30, 2010 Bureau of Labor
Statistics
◦ Consumer Price Index (urban) = +1.1%

Less productivity adjustment
◦ Estimated at 1.3%
◦ Negative 0.2%
◦ Cannot go below 0% adjustment

Less 1.75% starting 2011
◦ Overall projected adjustment -1.75%
◦ Second negative adjustment
DV & Associates, Inc.
65


December 1, 2010 without Congressional
change, -23.5% payment (SGR)
The Physician Payment and Therapy Relief Act
of 2010, passed Senate on November 18 but
still requires House passage and the
president's signature.
◦ Once signed, seniors and military families are
spared the threat of a lapse in care till the end of
the year
DV & Associates, Inc.
66

On January 1, 2011 without
congressional action:
◦ Another -6.1 % for 2011 (SGR)
◦ Total – 29.6% plus whatever happens to
component RVUs
DV & Associates, Inc.
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







CPT
88112
88173
88185
88189
88304
88305
88307
2011*
$111.72
$ 9.70
$54.94
$112.09
$68.21
$115.04
$246.31
2010
$101.77
$133.48
$47.20
$106.89
$61.95
$103.61
$212.76
% Increase
10%
12%
16%
19 6%
10%
11%
16%
DV & Associates, Inc.
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








CPTT
88312
88313
88331
88342
88346
88361
88367
88368
2011 *
$116.15
$84.81
$99.56
$113.20
$110.99
$164.82
$279.13
$239.31
2010
$99.93
$73.01
$89.60
$100.29
$99.56
$147.12
$239.67
$210.18
% Increase
16%
16%
11%
13%
11%
12%
16%
14%
DV & Associates, Inc.
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






If current CF retained - $36.8729:
CPT
88120
88121
88172
88177
88363
RVUs
13.47
11.37
1.49
0.82
1.12
Allowable
G$496.68
G$419.25
G$ 54.97
G$ 30.24
PC$ 41.30
DV & Associates, Inc.
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

CMS already announced end of TC billing
provision
Fought by various laboratory & pathology
groups
DV & Associates, Inc.
71

CMS finalizing policy to require ordering
provider’s signature on requisitions for
clinical diagnostic laboratory tests
reimbursed under the Medicare Part B CLFS
◦ Only affects paper requisitions

Various manuals being reconfigured to reflect
requirement
◦ Effective January 1?
◦ Still under siege by laboratory organizations
DV & Associates, Inc.
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
Test order can be any of the following
formats:
◦ A written document, signed by the treating
physician/practitioner, that is hand-delivered,
mailed, or faxed to the testing facility
◦ A telephone call by the treating
physician/practitioner or his or her office to the
laboratory
◦ Electronic mail, or other electronic means, by the
treating physician/practitioner or his or her office
to the laboratory
DV & Associates, Inc.
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


If the order is via telephone, both the treating
provider or provider’s office and the
laboratory must document the telephone
order in their respective copies of the
beneficiary’s medical record
Policy is thought to document a clear order
and assist with compliance
Signature requirement is not supposed to be
a burden to providers since they need to sign
orders anyway
DV & Associates, Inc.
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
Provider Enrollment, Chain, and Ownership
Chain
◦ Precipitated by Patient Protection and Affordable
Care Act (PPACA)
◦ Goal is to keep fraudulent entities from billing
Federal healthcare programs
◦ Ordering and referring physicians must be enrolled
in Medicare by July 1, 2010
 Or appropriately “opted out”
 Identified on claim
 Deadline extended to 2011
DV & Associates, Inc.
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• Document orders/referrals for 7 years or
lose enrollment for 1 year
 Referrals could be denied if ordering
physician not updated
 Potentially, pathologists who lack update in
enrollment may have internal orders internal
denied
 Includes:
◦ Address changes, complete physician name match,
CLIA information

“Drive by” site visits
DV & Associates, Inc.
76

Small Business Lending Act includes an
anti-fraud provision
◦ Sponsored by Sen. LeMieux of FL
◦ Signed by President on September 27
◦ Medicare start competitive bidding for “predictive
modeling” software contractors by January and
implement first in the 10 worst fraud states
◦ Goal to quit “pay and chase” to “first weigh and then
pay”
◦ Suspend payments to a provider where “credible
allegation” of fraud
DV & Associates, Inc.
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
Medicare just awarded grants to >50 Senior
Medicare Patrol Programs (SMPs)
◦ Increase awareness of M & M beneficiaries of fraud
prevention, identification, and reporting
◦ Increased funding for states known for high fraud
areas
◦ Administered by Administration on Aging
DV & Associates, Inc.
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Discussion
DV & Associates, Inc.
79
Diana