CMS announces HCPCS code G0452 for tests requiring  physician interpretation.

CMS announced it will raise the professional component (PC) of surgical pathology code 88305 by 2%, but lower the technical component (TC) of surgical pathology code 88305 by 52% in 2013.

HHS Announces Delay of  ICD-10  Date to October 1,2015

Creating a New Competitive Marketplace: Affordable Insurance Exchange Establishment Grants Awards List

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Posted: August 12, 2011 - 10:15 am ET


When the Affordable Care Act is fully implemented in 2014, individuals and small businesses will have access to affordable coverage through a new competitive private health insurance market – state-based Affordable Insurance Exchanges. On August 12, 2011, 13 states and the District of Columbia were awarded over $185 million dollars in Exchange Establishment grants. Three states, Indiana, Rhode Island and Washington, were awarded grants on May 23, 2011.

These grants are just the latest in an ongoing series of Affordable Care Act grants to help states develop Exchanges. Already, 49 states and the District of Columbia received Exchange Planning grants, seven states received Early Innovator grants, and a number of states have indicated interest for future rounds of Exchange Establishment grants. While states are moving at different rates in the planning and establishment process, the vast majority of states have already taken the crucial early steps in building these new marketplaces. Numerous states have already expressed interest in applying to future rounds to build a robust Exchange for their residents.

Affordable Insurance Exchange Grants

Affordable Insurance Exchanges will provide individuals and small businesses with a “one-stop shop” to find and compare affordable, quality private health insurance options. With these Exchanges, Americans will no longer be on their own in trying to find comprehensive, affordable health coverage that is right for their needs. Exchanges will bring new transparency to the market so that consumers will be able to compare plans based on price and quality. By increasing competition between insurance companies and allowing individuals and small businesses to band together to purchase insurance, Exchanges will help lower costs.

On January 20, 2011, the U.S. Department of Health and Human Services (HHS) announced a new funding opportunity for Exchange Establishment grants to help states continue their work to implement this key provision of the Affordable Care Act.

The Exchange Establishment grants recognize that states are making progress toward establishing Exchanges but are doing so at different paces. States can choose when to apply for grant funding based on their needs and planned expenditures and states will have multiple opportunities to apply for funding in the years ahead. Future applications for grants will be accepted quarterly, with the last deadline on June 29, 2012. Awards will be made approximately 45 days after the application due date. This process gives states maximum flexibility and ensures that states can move forward on their own timetables as they work to build an Exchange

Each state’s insurance market is unique, and each state will require different levels of support as they create their Exchange. The final determination of each state’s grant award was made following a thorough examination of funding requested by the state, and an analysis of what would be a reasonable funding amount from the federal government.

There have been two previous series of grants to assist with the construction of state-based Exchanges:

  • Forty-nine states and the District of Columbia received up to $1 million in Exchange Planning Grants. Four territories received similar grants on March 21, 2011. States receiving these funds have used them to conduct studies on the feasibility of Exchanges, and conduct community forums to hear directly from residents on how Exchanges should be established.
  • Six states and a multi-state consortium led by the University of Massachusetts Medical School received over $241 million in Early Innovator grants to develop model Exchange IT systems. All Early Innovator states have committed to assuring that the technology they develop is reusable and transferable. Using the grants, they will develop the building blocks for Exchange IT systems, providing models for how Exchange IT systems can be created.

The following grantees applied before the March 30, 2011 deadline. Grants were awarded on May 23, 2011.

 North Carolina
North Carolina Department of Insurance
Amount Awarded: $12,396,019
Level of Funding: Level One

Summary: North Carolina will engage stakeholders, prepare analyses of outstanding policy decisions, and expand the existing eligibility system of the North Carolina Department of Health & Human Services to accommodate the Exchange. The state will also: develop requirements for the non-eligibility related Exchange functions to prepare any necessary procurements; prepare North Carolina’s consumer assistance program in anticipation of 2014 requirements; develop a work plan, budget, and evaluation plan for the North Carolina Health Benefit Exchange (NCHBE); develop a post-2014 financial sustainability plan; and support initial operational activities of NCHBE.

West Virginia
West Virginia Offices of the Insurance Commissioner
Amount Awarded: $9,667,694
Level of Funding: Level One

Summary: West Virginia will provide for several consumer quality and effectiveness related studies to ensure an efficient and value driven market transition into the Exchange, including further funding for actuarial services and economic modeling as envisioned under the Planning Exchange Grant. West Virginia will also use funding to: create tools for successful risk adjustment; undertake an Exchange issuer initiative and complete a producer and navigator strategic plan; allow for continued policy integration with constituent state agencies; and, develop a business and operational plan that will ensure financial sustainability by January 2015.

Maryland Department of Health and Mental Hygiene
Amount Awarded: $27,186,749
Level of Funding: Level One

Summary: Maryland will conduct policy development and detailed planning to build on the work of Maryland’s Exchange Planning Grant and Maryland’s Innovator Grant. The Level One Establishment Grant will result in data-driven and intensive policy analysis that will shape the technical and operational infrastructure of the Exchange. In addition, the activities performed with this funding will result in the rapid implementation of the Exchange IT platform, including product licensing, system integration, and independent verification and validation. The IT platform will be flexible to respond to forthcoming federal guidance and ongoing policymaking and input from Maryland stakeholders.

Pathology Updates

Complex Lab Test Demonstration Project

CMS on July 5 released several documents covering the complex lab test demonstration project authorized by §3113 of the Affordable Care Act. A complex lab test for these purposes is defined as “an analysis of gene protein expression, topographic genotyping, or a cancer chemotherapy sensitivity assay.” The CPT codes that describe such tests include 83890-83914 (molecular diagnostics), 86294-86304 (tumor immunoassay), and several others.

In general, Medicare’s standard date of service rules stipulate that a clinical lab test that’s ordered by the treating physician within 14 days of a patient’s discharge from a hospital can only be billed by the hospital—the performing laboratory must bill the hospital, and the hospital bills Medicare. During the demonstration project period, participating laboratories “may bill Medicare directly for a complex clinical laboratory test which is ordered by the patient’s physician less than 14 days following the date of the patient’s discharge from the hospital or [critical access hospital].” The objective of the demonstration project is to evaluate the permitted change in performing laboratory billing arrangements on “access to care, quality of care, health outcomes, and expenditures.”

Participation in the demonstration project is voluntary. Laboratories that elect to participate and to bill Medicare directly for complex lab tests for hospital patients must submit claims for such tests with “a Project Identifier 56 for a test that appears on the Demonstration Test List.” (CMS hasn’t yet said exactly where within the standard Form CMS-1500 format the project identifier is to appear.) Heads-Up: If a participating laboratory wishes to bill Medicare for a complex lab test that doesn’t appear on the Demonstration Test List, it must file a request for a temporary G-code from CMS no later than August 1.

Proposed Reversal of Requesting Physician Signature Policy

In the Nov. 29, 2010 Federal Register CMS published a policy change that would “require a physician’s…signature on requisitions for clinical diagnostic laboratory tests paid under the [clinical laboratory fee schedule]” starting Jan. 1, 2011. Some people, including the author of Pathology Service Coding Handbook, believe that CMS expects this policy change to apply to requisitions for surgical pathology and cytopathology services as well, although the College of American Pathologists holds a contrary position based on verbal input from CMS.

Pressure from the laboratory industry and others caused CMS to delay implementing the new policy well into 2011. Now CMS has published a proposed rule that “would retract the policy [it] finalized in the [11/29/10 Federal Register] and reinstate the prior policy that the signature of the [requesting] physician…is not required on a requisition for Medicare purposes for a clinical diagnostic laboratory test paid under the CLFS.” {Federal Register, June 30, 2011, pgs. 38342-38347} The comment period on this proposed rule ends at 5:00pm (EDT) August 29.

Proposed Release of Physician Paid Claim Data

The Medicare paid claims data for each individual physician in your practice would be subject to release by CMS to “qualified organizations” if a proposed rule in the June 8 Federal Register goes into effect. According to CMS Administrator Dr. Donald Berwick, the release of this data will “make it easier for employers and consumers to make smart decisions about their health care.” Furthermore, he asserts that physician paid claim data mining by eligible organizations “will result in higher-quality and more cost-effective care [and make] our health care system more transparent [which in turn] promotes competition and drives costs down.”

We believe that granting ill-informed and uninformed laymen access to Medicare paid claims data for individual pathologists would be a grave mistake. Pathologist “performance” and quality of care based on CPT procedure and ICD-9-CM diagnosis codes would be subject to diverse and erroneous interpretation. The comment period for this proposed rule closes at 5:00pm (EDT) August 8.

CMS Proposes to Eliminate TC-Bundling “Grandfather” Exception

CMS is once again proposing to eliminate the ability of independent laboratories to directly bill Medicare Part B for the technical component (TC) of anatomic pathology procedures for certain qualifying hospital inpatients and outpatients. The hospital TC-bundling “grandfather” exception was first introduced by Congress via §542 of BIPA-2000. If CMS’s wish finally comes true, the change in independent laboratory billing arrangements will go into effect Jan. 1. The College of American Pathologists is expected to petition Congress for another extension of the hospital TC-bundling “grandfather” exception beyond its current expiration date of Dec. 31, 2011.

New PQRS Pathology Codes for 2012

CMS’s proposed rule for the CY2012 physician fee schedule, due for publication in the Federal Register sometime next month, includes at least three new Physician Quality Reporting System (PQRS) quality reporting measures for surgical pathologists. They are (1) Barrett’s esophagus (dysplasia is/is not detected in a biopsy diagnosed with Barrett’s esophagus); (2) pT and pN categories, Gleason score, and margin assessment reported for radical prostatectomy specimens; and (3) quantitative Her-2/neu immunohistochemistry result reported with applicable breast cancer specimens. The breast and colorectal cancer PQRS quality measures that have been in effect for surgical pathologists since 2008 will remain available for use in 2012 as well.

Three additional measures developed by the American Society of Breast Surgeons may be reportable by surgical pathologists starting Jan. 1, depending on their final specifications to be announced at a later date. They are (1) preoperative diagnosis of breast cancer; (2) sentinel lymph node biopsy for invasive breast cancer; and (3) biopsy follow-up.

Pathologists who successfully report the breast and/or colorectal cancer PQRS quality measures in 2011 are eligible for a 1% bonus on their total Medicare allowed charges for the year. The bonus percentage will fall to one-half of one percent (0.5%) for the 2012 period.

Medicare Denials of 88363

Some subscribers report ongoing problems getting new molecular pathology sample selection code 88363 paid by Medicare when place of service 21 (inpatient) or 22 (hospital outpatient) is properly assigned to the claim. The typical contractor explanation is that code 88363 is only payable to a hospital under Medicare Part A, which of course is not true. This dilemma is being encountered only in relation to one or two Part B contractors. The problem is solely due to contractor error; CMS coverage policy for code 88363 unquestionably permits payment to pathologists in POS 21 and 22 situations

Revisions to Medicare’s Telemedicine Credentialing Rules

The May 5 Federal Register includes CMS’s final rule affecting hospital and critical access hospital (CAH) credentialing and privileging requirements for telemedicine services. CMS says the new rule removes unnecessary barriers to the use of telemedicine services. Furthermore, CMS expects the new rule to “provide more flexibility to small hospitals and CAHs in rural areas and regions with a limited supply of primary care and specialized providers.” The new rule for hospital and CAH credentialing and privileging of telemedicine services went into effect July 5.

Submitted By: Dennis Padget, President and Founder of DLPadget Enterprises, Inc. & Publisher of Pathology Service Coding Handbook