Health Information Management

Q/A: Reporting molecular pathology codes

APCs Insider, January 20, 2012

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Q: Addendum B of the APC updates for 2012 lists the new molecular pathology codes as status indicator E (noncovered service, not paid under OPPS). Our laboratory director has heard that we should report the new codes in addition to the codes that are payable. Can you explain why?

A: Providers use molecular pathology tests to detect the presence of specific genes. Currently, coders report these tests with multiple CPT® codes to describe the specific testing being performed. Reporting in this manner is sometimes referred to as “stacked” codes.

The AMA created new CPT codes for these tests to reflect the service with a single code for CY 2012, Claims data reflects the stacked codes that historically have been reported for these services. No one-to-one relationship maps the old codes to new codes, so no easy crosswalk between them exists.

Multiple current CPT codes will map to one new code, and one current CPT code will map to several new codes because they are reported for several types of testing. The result is multiple-to-one and multiple-to-multiple mapping that must be considered before payment rates can be determined.

CMS is depending on providers to report both sets of codes to facilitate mapping the new CPT codes to the current cost/pricing information. Assignment of status indicator E should allow this line item to pass through the Integrated Outpatient Code Editor without delaying claims. CMS will not reimburse for the new codes, but reporting in this manner will put the new code on the same claim with current codes for the service. This will allow CMS to analyze the claims with the individual codes and the combination of codes that were reported for future rate-setting under the Clinical Diagnostic Laboratory Fee Schedule. Transmittal 2386 provides the following guidance:

Effective January 1, 2012, under the hospital OPPS, hospitals are advised to report both the existing CPT “stacked” test codes that are required for payment and the new single CPT test code that would be used for payment purposes if the new CPT test codes were active.

Use of the word “advised” suggests this reporting is voluntary. However, providers must carefully consider the future impact if they don’t report both sets of codes. Incomplete and insufficient claims data will be used to determine the payment amount for these services. These molecular pathology tests are complex; if providers don’t report both sets of codes, the resulting payment determination could be insufficient for the services provided. Providers should read the entire section of the transmittal pertaining to reporting these codes.

Note that Transmittal 2386, which was published January 13, replaces Transmittal 2376.

Editor’s note: Andrea Clark, RHIA, CCS, CPCH, chairperson, CEO, and founder of Health Revenue Assurance Associates, Inc., in Plantation, FL, answered this question.

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