Health Information Management

CMS looking for comments on molecular pathology payments

APCs Insider, May 17, 2013

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The AMA revamped coding for molecular pathology beginning in 2012 and continuing in the 2013 CPT®  Manual. As a result, coders went from reporting stacked codes—one code for each part of a molecular pathology test—to reporting a single code for the entire test. Now CMS is trying to determine how to pay for those tests and the agency wants to hear from providers.

Medicare did not recognize the new molecular pathology codes in 2012, but it did for 2013. Payment is based on the Clinical Laboratory Fee Schedule. Because these are new codes, each MAC will come up with its own rates this year, primarily using what’s called the gap-fill method.
CMS recently published the payment rates for the molecular pathology codes by state. Not all MACs provided payment information for each code. In addition, CMS did not publish payment rates for Tier 2 molecular pathology codes.
 In some cases, payment varies widely from one MAC to another. Consider CPT code 81226 (cytochrome p450 genotyping). First Coast, the MAC for Florida, Puerto Rico, and the US Virgin Islands, lists payment for CPT code 81226 as $505.76. Cahaba, the MAC for Alabama, Georgia and Tennessee, will pay only $50 for the same test.
Not all of the differences are that dramatic, but even a $10 or $15 difference could mean that labs in one MAC jurisdiction receive enough payment to cover the costs of performing the test and others don’t.
CMS has not yet set national payment rates for molecular pathology codes, so now is your chance to tell CMS what you think you should be paid and why. Don’t forget the why. Just telling CMS you want more money isn’t going to cut it. You need to provide hard data. Show CMS how much it costs you to perform the test.
The more people who comment and provide data the better. Healthcare organizations often believe they receive inadequate reimbursement for services. CMS is now giving you the chance to have a say. Prove you case and you’ll help not only yourself, but other providers as well.
I spoke with Jugna Shah, MPH, president and founder of Nimitt Consulting, and Michelle L. Ruben, project manager of revenue and rate setting strategy at M.D. Anderson Cancer Center in Houston, to get their thoughts on the proposed payment. Look for the article in the next issue of Briefings on APCs.
Clarification: One point of clarification on last week’s note on the outpatient therapy caps. The cap is not intended to be a treatment guideline. It’s a payment cap. So if the provider documents the medical necessity of therapy services that exceed the cap and provides a plan of care, bill for the services. If the services exceed the cap, make sure you have the documentation to support the additional services. You should have that documentation for all services, so you’re not asking the provider to do anything extra.

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