IHC denials

[ygdrasil]

There's been an increase in our denials for 88342s and 88341s from CMS, which they explained was due to our report not documenting the "why" of different stains performed on different specimens. We currently use language like "An immunostain for p63 is performed on blocks G-1, H-1 and K-1. The results support the above diagnoses." or "Single lymph node negative for tumor by H&E and immunostain for keratin."
Any advice as to how we can better document our rationale?

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[coroner]

This is a new policy required by CMS. Our billing company actually gave us a heads up regarding this recently to make sure we're on board to prevent such denials. In the old days, it was good enough to say how many immunostains you did and bill 88342 for all of them. Palmetto did a study on H.P.'s and PIN-4's showing many pathologists were a couple of standard deviations off which is what partly elicited this new policy.

Anyway, it sounds like they are being real nitpicky towards your practice (unsurprisingly) so I would think minor tweaks should prevent it from getting bounced back. e.g. "A p63 IHC shows an intact myoepithelial layer", "A pankeratin IHC is negative for metastatic ca.", etc. We use this kind of language and haven't had a problem thus far. Although, if you're saying "single lymph node negative for tumor..." I would think that should suffice, so it's a little peculiar that would get denied. But, it's their ball game, so we have to play by their rules...

 

[Path or bust]

There's been an increase in our denials for 88342s and 88341s from CMS, which they explained was due to our report not documenting the "why" of different stains performed on different specimens. We currently use language like "An immunostain for p63 is performed on blocks G-1, H-1 and K-1. The results support the above diagnoses." or "Single lymph node negative for tumor by H&E and immunostain for keratin."
Any advice as to how we can better document our rationale?

We haven't gotten denials from CMS. We list every stain and describe its purpose:

Immunostains with working controls on block A1:
P63: positive in basal cell layer
PSA: strongly positive in tumor cells
AE1/AE3: strongly positive in tumor cells
Estrogen receptor: negative in cells of interest

Special stains with working controls:
GMS stain: negative for fungus.

 

[deleted314957]

What a sad state of affairs. As sure as the sun rises they will soon do away with all forms of the current "ala carte" payment system and then such convolutions will be
only a memory. The gov't wants you to be (essentially) an employee so they can drop the charade of documenting "medical necessity" and just tell you what you can and cannot order.
The non-compliant or the "trouble makers" will be canned or financially penalized.
It seems we are very close to that now. They do not care if you operate at a profit or a loss. They are boiling the frog.

 

[ygdrasil]

What a sad state of affairs. As sure as the sun rises they will soon do away with all forms of the current "ala carte" payment system and then such convolutions will be
only a memory. The gov't wants you to be (essentially) an employee so they can drop the charade of documenting "medical necessity" and just tell you what you can and cannot order.
The non-compliant or the "trouble makers" will be canned or financially penalized.
It seems we are very close to that now. They do not care if you operate at a profit or a loss. They are boiling the frog.

Thanks for your replies. It sure can feel like that, mikesheree. The goal posts keep moving, our regulation and documentation burden keeps increasing. On this particular issue, however, it's currently not that many denials and not a significant cost to our group. It's also frustratingly random- plenty of CMS claims with equivalent documentation of IHC usage are approved. One imagines bored bureaucrats ruling one way on Tuesday because they'd had sufficient caffeine and another way on Wednesday because they were up late watching Westworld.

Path or Bust: That's quite a lot more detail than we go into. I'll start ramping up my microscopic descriptions.

 

[WEBB PINKERTON]

We are having issues with CMS over 88333, 88334, 88172 and 88177. Documenting those assessments is becoming a HUGE burden.

 

[stickyshift]

We are having issues with CMS over 88333, 88334, 88172 and 88177. Documenting those assessments is becoming a HUGE burden.

My assessment documentation is essentially my microscopic description, only longer.

 

[cmz]

I usually list out all of my IHC and state what stain, etc. The only cases where I don't do that to some degree is my Helicobacter IHCs, but I do state if HP organisms are seen by HP IHC in my dx line and later report if the stain is positive or negative in the micro.

 

[LADoc00]

Hmm I have so much $ coming in as just passive income streams now, only like 40ish % I actually rely on billing. It's nice to wake up and say "Yah not really caring what Noridian/CMS publishes in their crazy crap newsletter today".

Passive income streams>all=win.

I actually gave a mini-lecture on this once. Entitled "The Retainer: How to Give Zero F--cks in Today's Healthcare Environment"

 

[yaah]

We are not getting denied billing but I recall seeing things that said reports using immunostains would need to justify them. I typically say, "Immunostains for x, y, and z performed to characterize the neoplastic cells" or "to evaluate an atypical focus." Have no idea whether it helps or not but it is not a big burden to add it.