4 Top Trends in Pathology Billing and Coding

Labs nationwide have faced significant billing and coding challenges over the past few years. These challenges are likely indicative of trends labs can expect to face in the coming years. Here is a quick snapshot of four of the top lab billing and coding trends.

1. Reduced reimbursement. Reimbursement cuts have hit providers of most services, but pathology saw one of the most drastic reductions in 2013 when the 2013 Physician Fee Schedule rule saw CMS cut the technical component of CPT code 88305 (Level IV– Surgical pathology, gross and microscopic examination) by 52%. While CMS raised the professional component by 2%, the revaluation resulted in an overall 33% decrease to the global payment for 88305, as noted in a College of American Pathologists FAQ (pdf).

2. Reduced coverage. As if reimbursement cuts weren't bad enough, The Pathology Blawg is reporting that certain Medicare Administrative Contractors (MACs) have recently submitted draft local coverage determination policies that would eliminate coverage of select urine drug toxicology tests. It would not be surprising to see other MACs follow suit.

3. Shift away from out-of-network. Labs have long-faced challenges in gaining access to restricted insurance networks, but at least if a lab wasn't in-network with a payer, there was the option of handling and billing for specimens if the patient had out-of-network (OON) coverage.

But there's been a shift in the marketplace in the types of insurance products offered to consumers, and more of these products are HMOs that do not include any OON benefit. With the number of plans that include OON benefits dwindling, this is a revenue stream that appears to be gradually drying up for labs.

4. Coding changes. In 2013, all of the codes for molecular pathology tests were changed, and there were significant changes in anatomical coding for CPT codes 88342 and 88343. Coding changes present plenty of challenges on their own, but along with these changes came changes to the reimbursement methodology.

To make matters worse, the issuing of the information on the changes to the reimbursement methodology were delayed because Medicare carriers had to come up with the reimbursement formula. Since labs had to wait to receive the methodology, this then caused a delay in payments to the labs. It would not be surprising to see this pattern repeat again.

Value of Outsourcing

With pathology facing these and other challenging billing and coding trends, labs cannot afford to leave any money on the table. More and more labs are turning to the services of a medical billing company like PGM Billing to take over their billing and ensure all reimbursement dollars earned are captured. An experienced company like PGM will increase a lab's revenue by boosting collection rates, reduce denials and delays in payment, and allow a lab to save money in billing staff salaries and benefits, training, and IT equipment and software.

Transition From ICD-9 to ICD-10 Delayed to 2015

The U.S. Senate has passed a bill that will delay the transition from the ICD-9 code sets to the ICD-10 code sets.

President Barack Obama is expected to sign the bill (pdf) into law, according to numerous reports.

The bill pushes back the compliance deadline for ICD-10 from Oct. 1, 2014, to Oct. 1, 2015, at the earliest.

This is not the first time implementation of ICD-10 has been delayed. In August 2012, the Department of Health and Human Services announced it approved a one-year delay from Oct. 1, 2013, to Oct. 1, 2014

In the bill, the Senate also approved the so-called "doc fix" that suspends the Medicare sustainable growth rate formula for one year. The House had approved the bill last week. It is the 17th time Congress has temporarily delayed cuts of nearly 24 percent to physician reimbursement under Medicare.

History of Chiropractic Care

The roots of chiropractic care can be traced all the way back to the beginning of recorded time. Writings from China and Greece written in 2700 B.C. and 1500 B.C. mention spinal manipulation and the maneuvering of the lower extremities to ease low back pain. Hippocrates, the Greek physician, who lived from 460 to 357 B.C., also published texts detailing the importance of chiropractic care. In one of his writings he declares, "Get knowledge of the spine, for this is the requisite for many diseases".

In the United States, the practice of spinal manipulation began gaining momentum in the late nineteenth century. In 1895, Daniel David Palmer founded the Chiropractic profession in Davenport, Iowa. Palmer was well read in medical journals of his time and had great knowledge of the developments that were occurring throughout the world regarding anatomy and physiology. In 1897, Daniel David Palmer went on to begin the Palmer School of Chiropractic, which has continued to be one of the most prominent chiropractic colleges in the nation.

Throughout the twentieth century, doctors of chiropractic gained legal recognition in all fifty states. A continuing recognition and respect for the chiropractic profession in the United States has led to growing support for chiropractic care all over the world. The research that has emerged from " around the world" has yielded incredibly influential results, which have changed, shaped and molded perceptions of chiropractic care. The report, Chiropractic in New Zealand published in 1979 strongly supported the efficacy of chiropractic care and elicited medical cooperation in conjunction with chiropractic care. The 1993 Manga study published in Canada investigated the cost effectiveness of chiropractic care. The results of this study concluded that chiropractic care would save hundreds of millions of dollars annually with regard to work disability payments and direct health care costs.

Doctors of chiropractic have become pioneers in the field of non-invasive care promoting science-based approaches to a variety of ailments. A continuing dedication to chiropractic research could lead to even more discoveries in preventing and combating maladies in future years.

Education of Doctors of Chiropractic
Doctors of chiropractic must complete four to five years at an accredited chiropractic college. The complete curriculum includes a minimum of 4,200 hours of classroom, laboratory and clinical experience. Approximately 555 hours are devoted to learning about adjustive techniques and spinal analysis in colleges of chiropractic. In medical schools, training to become proficient in manipulation is generally not required of, or offered to, students. The Council on Chiropractic Education requires that students have 90 hours of undergraduate courses with science as the focus.

Those intending to become doctors of chiropractic must also pass the national board exam and all exams required by the state in which the individual wishes to practice. The individual must also meet all individual state licensing requirements in order to become a doctor of chiropractic.

An individual studying to become a doctor of chiropractic receives an education in both the basic and clinical sciences and in related health subjects. The intention of the basic chiropractic curriculum is to provide an in-depth understanding of the structure and function of the human body in health and disease. The educational program includes training in the basic medical sciences, including anatomy with human dissection, physiology, and biochemistry. Thorough training is also obtained in differential diagnosis, radiology and therapeutic techniques. This means, a doctor of chiropractic can both diagnose and treat patients, which separates them from non-physician status providers, like physical therapists. According to the Council on Chiropractic Education DCs are trained as Primary care Providers.

What is a Doctor of Chiropractic?
The proper title for a doctor of chiropractic is "doctor" as they are considered physicians under Medicare and in the overwhelming majority of states. The professional credentials abbreviation " D.C." means doctor of chiropractic. ACA also advocates in its Policies on Public Health that DCs may be referred to as (chiropractic) physicians as well.

Chiropractic Philosophy
As a profession, the primary belief is in natural and conservative methods of health care. Doctors of chiropractic have a deep respect for the human body's ability to heal itself without the use of surgery or medication. These doctors devote careful attention to the biomechanics, structure and function of the spine, its effects on the musculoskeletal and neurological systems, and the role played by the proper function of these systems in the preservation and restoration of health. A Doctor of chiropractic is one who is involved in the treatment and prevention of disease, as well as the promotion of public health, and a wellness approach to patient healthcare.

Scope of Practice
Doctors of chiropractic frequently treat individuals with neuromusculoskeletal complaints, such as headaches, joint pain, neck pain, low back pain and sciatica. Chiropractors also treat patients with osteoarthritis, spinal disk conditions, carpal tunnel syndrome, tendonitis, sprains, and strains. However, the scope of conditions that Doctors of chiropractic manage or provide care for is not limited to neuromusculoskeletal disorders. Chiropractors have the training to treat a variety of non-neuromusculoskeletal conditions such as: allergies, asthma, digestive disorders, otitis media (non-suppurative) and other disorders as new research is developed.

Works Cited
Chapman-Smith, David: The Chiropractic Profession. West Des Moines, Iowa, NCMIC Group Inc., 2000: 11-17, 70-71.
Chiropractic: State of Art. Arlington, Virginia, American Chiropractic Association, 1998: 2-3, 12-14.
Spinal Manipulation Policy Statement. Arlington, Virginia: American Chiropractic Association, 1999: 6.

Medicare Increases Scrutiny of Anesthesia Billing

Medicare is increasing its scrutiny of anesthesia billing as a result of recovery auditors finding a high percentage of errors involving the incorrect use of the HCPCS modifiers for anesthesia. These errors are specifically associated with situations when anesthesia was provided by a CRNA and anesthesiologist without a 50% reduction as per Medicare guidelines involving CRNAs supervised by anesthesiologists.

This is according to a recent issue of Medicare Quarterly Provider Compliance Newsletter (pdf), a newsletter from CMS developed to help providers understand the major findings identified by Medicare administrative contractors, recovery auditors and other governmental organizations, such as the Office of Inspector General.

As the newsletter notes, auditors determined that when anesthesiologists append modifiers -QY, -QK, or -AD, they are stating the procedure was supervised, and accept 50% of the fee schedule payment. When the CRNA states, through the use of the -QZ modifier, that the same procedure was not supervised and accepts 100% of the fee schedule, an overpayment to the CRNA exists.

Here are two scenarios CMS provided to illustrate overpayment scenarios:

Example: The CRNA billed HCPCS code 00142 (Anesthesia for procedures on eye; lens surgery) with modifier -QZ (CRNA service: without medical direction by a physician) for date of service of May 18, 2010. However, for the same beneficiary, the same procedure code and date of service, the anesthesiologist billed with a -QK modifier (Medical direction of two, three, or four concurrent anesthesia procedures involving qualified individuals), triggering an overpayment.

Example: The CRNA billed HCPCS code 01215 (Anesthesia for open procedures involving hip joint; revision of total hip arthroplasty) with modifier -QZ (CRNA service: without medical direction by a physician) for date of service August 1, 2011. For the same beneficiary, procedure code and date of service, the anesthesiologist also submitted a claim with a -QY modifier (Medical direction of one CRNA by an anesthesiologist), triggering an overpayment.

How to Avoid These Problems

When submitting bills in instances where the anesthesiologist supervises a case and the CRNA provides the anesthesia services, CMS notes that their total compensation should not exceed 100% of the highest fee schedule of the anesthesiologist or CRNA.

Therefore, when anesthesiologists append modifiers -QY, -QK or -AD, they are stating the procedure was supervised, and accept 50% of their fee schedule payment.

The CRNA must be careful when stating, through the use of the -QZ modifier, that the procedure was truly not supervised. If the CRNA is supervised and accepts 100% of the fee schedule, an overpayment to the CRNA exists.

If you are struggling to properly bill for anesthesia services, consider outsourcing your medical billing for anesthesiologists and CRNAs to one of the nation's leading anesthesiology billing vendors: PGM Billing. PGM has more than 30 years of coding and billing experience, with a team of certified, expert billers dedicated to anesthesia billing. PGM will help ensure you receive the correct reimbursement for the anesthesia services you deliver while avoiding improper billing that could bring increased scrutiny from the federal government upon your organization.

Vintage Medicare Poster from 1968

This 1968 poster informs seniors about the Medicare program that was added to Social Security in 1965 (first benefits payable in 1966). Today, nearly 50 million Americans — 15 percent of the nation's population — depend on Medicare for their health insurance coverage. With increasing life expectancies and more boomers turning 65 every day, the number of people in Medicare is expected to double by the year 2030.



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