The Centers for Medicare & Medicaid Services (CMS) developed the National Correct Coding Initiative (NCCI) to promote national correct coding methodologies and to control improper coding that leads to inappropriate payment of Part B claims. The coding policies are based on coding conventions defined by various credentials such as the CPT manual, local and national Medicare policies and edits, coding guidelines, current coding practice, and standard medical and surgical practice. This upcoming year has many changes that affect laboratory coding, billing and payments. Specifically, this article will discuss the procedural coding changes for 2019 and the proposed changes in government reimbursement. In addition, there are relevant policies and issues affecting coverage. As well as, the impact of CMS editing systems. In turn, the changes provide the implementation of new codes and policies to influence patient care.
Procedural Coding Changes for 2019
The PAMA had their lawsuit dismissed against them after they were accused of having CLF’s changes incorrectly calculated. This was determined to not be true. Therefore, the CMS’s determination of payment rates cannot be challenged. Also, the ACLA Website filed an appeal on October 19 to Protecting Access to Medicare Act (PAMA). This included calling on Congress to reform and modernize the Clinical Laboratory Fee Schedule to ensure that beneficiaries can continue to access the lab sevices and diagnostics they need.
New Tier 1 Codes
Almost 50 new codes have been added for the 2019 year. Some of the new CPT codes include TERT, TGFBI, EZH2, BTK, PLCG2, MYD88, NUDT15, AFF2, AR, ATN1, ATXN1, ATXN10, ATXN2, ATXN3, ATXN7, ATXN8OS, CACNA1A, CNBP, CSTB, DMPK, FXN, HTT, PABPN1, SMN1, TBP, and PPP2R2B.
BRACA Coding
BRACA coding was determined to be one of the top 25 frequently paid laboratory tests. In 2017, Medicare spent $52M on this testing. There was a description revision which included BRACA1 (BRCA1, DNA repaired associated), BRACA2 (BRCA2, DNA repaired associated), (eg, hereditary breast and ovarian cancer) gene analysis; a full sequence analysis and full duplication/deletion analysis (ie, detection of large gene arrangements). In addition, description change also affects new and other indented codes. The two new CPT BRACA codes also have a price change depending on which code is ordered. For instance 81163 is $468 and 81164 (full duplication/deletion analysis) is $584. Lastly, there are parenthetical comments have been updated dependent upon which CPT is ordered.
New Panel Codes
The new panel code includes CPT 81443, which is genetic testing for severe inherited conditions. The genomic sequence analysis panel must include sequencing of at least 15 genes.
New MAAA Code
There are new MAAA codes that refer to infectious disease and oncology. The deleted MAAA Code is 0001M (Infectious disease, chronic hepatitis C virus (HCV) infection, six biochemical assays utilizing serum, prognostic algorithm reported as scores f or fibrosis and necroinflammatory activity in liver).
Quad Testing for Fetal Congenital Disorders
The CPT 81511 will utilize maternal serum to test for fetal congenital abnormalities.
Reconsidered Test Codes
This year two test codes went under consideration, which included 81326 and 81334. The 81326 CPT refers to PMP22 (eg, Charcot-Marie-Tooth, hereditary neuropathy with liability to pressure palsies). In addition, the 81334 CPT describes RUNX1 (eg, acute myeloid leukemia, familial platelet disorder with associated myeloid malignancy).
Proprietary Laboratory Analyses Codes
New PLA codes become effective in the quarter following their approval and publication. PLA test codes are released on a quarterly basis and published on the CPT public website at http://www.ama-assn.org/practice-management /cpt-pla-codes. PLA subsection includes ADLTs and CDLTs. CDLTs are defined by the Centers for Medicare & Medicaid Services (CMS) as tests that include blood tests, urinalyses, tests on tissue specimens, some screening and other tests. PAMA says ADLTs as covered under Medicare Part B that is offered and furnished only by a single laboratory. PLA 0018U through 0061U was added in the 2019 CPT and can be reviewed on the CPT or AMA website. These are carrier priced until discussed at annual clinical laboratory public meeting in July. Deleted PLA codes included several CPT codes. For instance, 0004U, which describes Infectious disease (bacterial). In addition, 0015U, which refers to Drug metabolism (adverse drug reactions), and 0020U which refers to Drug test(s), presumptive, with definitive confirmation of positive results, and any number of drug classes. Lastly, 0028U which describes CYP2D6 (eg, drug metabolism).
New Chemistry codes
Two new chemistry codes include 82642 and 83722. CPT 82642 refers to Dihydrotestosterone (DHT). Clinicians may order DHT testing for prostate cancer patients undergoing 5 alpha-reductase inhibitor therapy or chemotherapy (may need to monitor DHT serum levels for patients undergoing certain prostate cancer treatments). Lastly, CPT 83722, which describes a Lipoprotein, direct measurement; small dense LDL cholesterol. This may help identify patients with hereditary high LDL or LPA lipoprotein (a) deficiency. This deficiency is a key component in progression of atherosclerosis and cardiovascular disease
Fine Needle Aspiration Biopsy
Multiple new codes have been added for fine needle aspiration biopsy. Code reporting may be “mixed and matched”. However, imaging cannot be separately reported; it is bundled in the new codes. In addition, Modifier 59 will need to be reported when an add on code does not match the primary code. In addition, there was a deletion of 10022, which referred to imaging. Lastly, there are various payment changes dependent upon which CPT code is ordered.
Other Pathology
The MPFS achieved a victory when the CPT 85390-26 Fibrinolysis or coagulopathy screen, interpretation and report had a 104% increase to $38.21. In addition, there have been significant flow cytometry rate cuts. For example, 88185 (FC each additional marker) and 88187 (FC interpretation; 2 to 8 markers) cut by -19%. Also, 88184 (Flow cytometry first marker) cut by -3%. Lastly, IHC Morphometric Analysis showed positive and negative percentage impact dependent upon IHC manual and comput.
References:
https://www.ama-assn.org/practice-management/cpt-current-procedural-terminology
NCCI Policy Manual for Medicare Services – Effective January 1, 2019
Medical & Clinical Laboratory Software 