Anyone else getting fleeced on the new PIN-4 codes?

[coroner]

Was looking at some figures in our practice recently and now starting to see the effects from the fee scheduling changes enacted at the beginning of the year. With the new CMS coding of an 88344 issued for prostate cocktails, reimbursement has been drastically altered. Just talked with my lab manager today and he said the 88344 Part B Medicare reimbursement for a PIN-4 is roughly $240 whether we do it for 1 or 12 parts. The cost of reagents is $63 per specimen. That means if you’re running it on all specimens in a twelve-part biopsy (like some practices have been known to do) that’s going to cost $756. For those who run it on all twelve parts, they will be losing about $500 per case for their hospital/lab on Medicare patients. Heck, even if there were multiple areas with ASAP, only four can be stained just to breakeven on the technical. Sure, the pathologists are coming out ahead on the professional component, but you could see how this will be curtailed when hospitals are crunching numbers and start seeing the loss. Once again, we’re seeing how the questionably greedy practices of a few have caused the pendulum to swing too far the other way and affect the masses… Did anyone else’s practice get hit; and if so, how significantly? Are there any coding modifiers or anything else you guys are doing or just chalk it up as a loss?

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[Sulfinator]

Doing a PIN-4 on all 12 cores on all cases is ridiculous!

 

[pongo]

The G codes for prostate have been great for us, since we never get more than 6 bottles, and often get 2 or 4. We don't do much IHC for prostate, only an occasional HMWCK or p63. Lately the urologists don't care with most patients if we call it small atypical focus or small focus of cancer, since it doesn't change their management. If it is important, they do concentrated biopsies subsequently. This appears to be how Epstein's group approaches these, and they never seem to do immunos.

 

[LADoc00]

Your office manager is wrong. You can definitely bill and get paid on more than one 88344 per G-code prostate. It requires you to bill each 88344 on separate lines I believe.

I dont do 88344s anyway, I have swapped over to 88360s on prostate immunos, which I do alot of. CMS will pay for up to 6x88360s per G-code prostate.

This comes out to roughly 800+960 or 1760 per 6-part prostate at CMS reimbursement levels.

 

[pongo]

What are you quantifying?

 

[pathstudent]

What are you quantifying?

If people start quantifying immunos which are performed to qualify, 88360 and 88361 will be next on the chopping block.

 

[coroner]

Doing a PIN-4 on all 12 cores on all cases is ridiculous!

Spoken like a true academician (or someone still in training)…

I never advocated this. In fact, I said it’s because of greedy practices who did this which caused reimbursements to decline. My problem is when the costs of running a test which has diagnostic utility end up as a loss for the lab and they won’t run it anymore.

Your office manager is wrong. You can definitely bill and get paid on more than one 88344 per G-code prostate. It requires you to bill each 88344 on separate lines I believe.

Yup, talked with lab manager again today and checked this. An 88344 can be billed per specimen with a modifier known as “88344-59” x 6 or 12, which justifies medical necessity. Our billing rep ran this through and it seemed to pass.

On a side note, I learned that in addition to running the 88344 with the "59" modifier, it may be possible to also run an 88342 for the first specimen and 88341 for any subsequent ones as well. The reason is the P504s is from a different vendor than the dual cocktail for the basal layer and they are then combined later. Again, practice manager/billing team is verifying this.

I dont do 88344s anyway, I have swapped over to 88360s on prostate immunos, which I do alot of. CMS will pay for up to 6x88360s per G-code prostate.

Interesting, I will run this by colleagues and lab manager to see if we should make the switch…

If people start quantifying immunos which are performed to qualify, 88360 and 88361 will be next on the chopping block.

Everything is always on the chopping block in this line of work. Because there will be always be those unscrupulous few who try and milk the system or want a bigger piece of the pie whether it’s on the physician’s side or hospital/insurance company/ gov’t side. It’s the name of the game. That’s why you get in when the going’s good and know when to adapt or get out…

 

[pathstudent]

Everything is always on the chopping block in this line of work. Because there will be always be those unscrupulous few who try and milk the system or want a bigger piece of the pie whether it’s on the physician’s side or hospital/insurance company/ gov’t side. It’s the name of the game. That’s why you get in when the going’s good and know when to adapt or get out…

So I will adapt by quantifying all immunos.

100% of the cells are TTF-1 positive
100% of the cells are CK7 postiive
0% are CK20 positive.

88360x3.

 

[pongo]

Attended a lecture from the Palmetto GBA lady who wrote the ancillary stain LCD, and she had multiple PowerPoint slides highlighting abuse of 88360. I'm having trouble seeing how using these codes for prostate IHC doesn't fit her definition of abuse. Seems like a big risk for modest reward to me.

 

[Sulfinator]

Spoken like a true academician (or someone still in training)…

I never advocated this. In fact, I said it’s because of greedy practices who did this which caused reimbursements to decline. My problem is when the costs of running a test which has diagnostic utility end up as a loss for the lab and they won’t run it anymore…

Yeah, I wasn't saying you were an advocate. I was just gasping at how much unnecessary work up was being done by labs that have that kind of protocol.

 

[cmz]

So can I use 88360 when I use CD34 to estimate the number of blasts in my bone marrows and Ki-67 to estimate the proliferation index in my lymphomas?

 

[coroner]

Yeah, I wasn't saying you were an advocate. I was just gasping at how much unnecessary work up was being done by labs that have that kind of protocol.

I know Sulf, just bustin' your ballz a little bit... Good luck with the new job.

So can I use 88360 when I use CD34 to estimate the number of blasts in my bone marrows and Ki-67 to estimate the proliferation index in my lymphomas?

Almost reminds me of when they use to run a ploidy analysis on every breast ca (which included a Ki-67). Now that was milking the cow...

 

[cmz]

I know Sulf, just busting your ballz a little bit... Good luck with the new job.



Almost reminds me of when they use to run a ploidy analysis on every breast ca (which included a Ki-67). Now that was milking the cow...

So you're staying there is still a chance...

 

[Sulfinator]

Good luck with the new job.

Thanks, Coro.

 

[pathstudent]

So can I use 88360 when I use CD34 to estimate the number of blasts in my bone marrows and Ki-67 to estimate the proliferation index in my lymphomas?

Yes. Those are legitimate uses of 88360. Manual quantification of blasts, ER positive cells, etc....

 

[Sulfinator]

Yes. Those are legitimate uses of 88360. Manual quantification of blasts, ER positive cells, etc....

Does it have to be a hard core manual count (as in using a gridded field)? I'm assuming just a gestalt is not good enough.

 

[yaah]

In our group, PIN4 is done on about 10% of prostate biopsy cases. In almost all of those, it's on one block.

I don't really understand doing it routinely on multiple blocks.

If you're losing money because you're doing it on too many blocks seems to me that justifies the billing practice, unfortunately.

 

[cmz]

Does it have to be a hard core manual count (as in using a gridded field)? I'm assuming just a gestalt is not good enough.

Eyeballing it is good enough I think (at least from what I've read). However, I have performed a manual CD34 count on nucleated cells before on semi-difficult AML/MDS cases.

 

[icpshootyz]

So can I use 88360 when I use CD34 to estimate the number of blasts in my bone marrows and Ki-67 to estimate the proliferation index in my lymphomas?

Weren't these always legitimate uses for 88360?

 

[coroner]

Ok, here’s what I found out after looking into this a bit more and speaking with practice manager and another business contact of mine:

Running the PIN-4 can only be billed as an 88344 legally. It can be charged 6X or 12X (or however many cores) with the “59” modifier. Unfortunately CMS will only reimburse up to 88344x5. The reimbursement is of course way less than the 88342x36 that we were able to do as recently as 2013; but that goose has no more golden eggs to lay…

After doing a PIN-4, you can’t charge for an 88342 or 88341 additionally even if the stains are manually combined by your lab or whether they’re from different vendors as I thought might be possible. The reason is because even if stains are combined, they are still on the same slide and not separately interpreted. I personally don’t want to be looking at three times the amount of glass nor have my histotechs slowed down by doing this for a few extra bucks.

I dont do 88344s anyway, I have swapped over to 88360s on prostate immunos, which I do alot of. CMS will pay for up to 6x88360s per G-code prostate.

This comes out to roughly 800+960 or 1760 per 6-part prostate at CMS reimbursement levels.

Don’t see how this is legit LA. Again, what are you quantifying that's medically justifiable? Unless you are using some kind of Jedi mind trick we don’t know about. If so, teach us the ways of the Force. If not, proceed with caution…

Attended a lecture from the Palmetto GBA lady who wrote the ancillary stain LCD, and she had multiple PowerPoint slides highlighting abuse of 88360. I'm having trouble seeing how using these codes for prostate IHC doesn't fit her definition of abuse. Seems like a big risk for modest reward to me.

That’s also what I recently learned. Sure, it may pay better, but if it's not medically justifiable (as in this case), it won't be deemed acceptable by Medicare/insurance companies. Again, if one is doing the cocktail and it’s on the same slide, they can only legally charge for an 88344. Anyone can charge for whatever they like e.g. 88360, 88342, etc. but good luck explaining that to CMS when they do an audit of your billing practice. They will classify that as straight up Medicare fraud. Not worth putting my career at risk…