IHC LCDs now in effect...really?

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LADoc00

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Does anyone have a handle on what the HELL is going on with the LCD shenanigans the CMS intermediaries are trying to pull? This borders on ridiculous and I am a complete loss on how they actually plan to enforce any of this crap.

From my reading to summarize:
If a prostate core ends up being negative after a PIN4, they aint paying.
If a gastric biopsy has H. Pylori IHC done, even if requested by the GI doc specifically, they aint paying.
If a breast case has the breast triple stain done, they aint paying.
If you order Ki-67 for almost any reason outside of some lymphomas, they aint paying.
If you order more than 2 (yes 2..) stains for lung carcinoma, they aint paying.

WHAT THE HELL IS HAPPENING?

Is this for real? I realize CAP is trying to a legislative work around but how in the heck are the intermediaries granted some incredibly broad power to simply deny payment to wide swaths of Medicare/Medical patients' care? We have CMS itself lowering payments and the fiscal intermediaries then compounding the situation with literally denying all the payments out of hand.

This is the G.D. apocalypse!
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Well it is worse than that. They may pay you today. Five years from now you can get a RAC audit targeting these codes .

If that happens then whole case get declared abuse/fraud not just the stains.
If they want to kick your ass, they use the False Claim ACT.
Then they can fine you 10k per code and or kick you out of the program.

You can imagine even a three person hospital group might have more than 500K in claims in 3-5 years if they still do Ki67 on their breasts.
The compliance aspects of pathology is making private practice too risky.

Welcome to the new world order.
 
I'm surprised there aren't more replies to this thread! If LA's account is a sentinel event of a more generalized process then we are totally screwed. The LCD originally was drafted to curb over-use of the IHC codes, and sent as a guideline for when IHC ordering is appropriate. However, if the interpretation is to decline the majority of IHC payments, then this will derail the practice of pathology significantly. If pathologists aren't reimbursed for IHC use such as those delineated by LADoc, then we won't be able to give accurate diagnoses!!
 
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I brought this up months ago as I have been working with cap on the legislative side. When I brought it up And said it was coming to Cali and the western U.S. he said I didn't know what I was talking about. But it seems I did know.
 
As a quality issue, CMS is requiring that all non-small cell lung cancer biopsies state whether it is squam or adeno or large cell etc.... Not uncommonly that requires a panel of IHC, so Palmetto and their equivalents saying they will only pay for 2 goes against that quality issue.
 
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The big issue is now MACs get to practice medicine according to their secret panel of doctors.
This is a giant MC journal club and their summary opinion always wins. It is always weighted to save money.
 
I'm surprised there aren't more replies to this thread! If LA's account is a sentinel event of a more generalized process then we are totally screwed. The LCD originally was drafted to curb over-use of the IHC codes, and sent as a guideline for when IHC ordering is appropriate. However, if the interpretation is to decline the majority of IHC payments, then this will derail the practice of pathology significantly. If pathologists aren't reimbursed for IHC use such as those delineated by LADoc, then we won't be able to give accurate diagnoses!!

If it comes to this, I'll sign everything out as a malignant neoplasm, defer to IHC or indeterminate for malignancy, defer and then refer them to the legal footnotes at the end of the report that I'll have risk management insert stating prior authorization from insurance will be required for further characterization and may delay the diagnosis and ultimately prompt care. Alternatively, you as the patient may break out the credit card if your so inclined and pay cash to know what you have to be treated properly.
 
I'm surprised there aren't more replies to this thread! If LA's account is a sentinel event of a more generalized process then we are totally screwed. The LCD originally was drafted to curb over-use of the IHC codes, and sent as a guideline for when IHC ordering is appropriate. However, if the interpretation is to decline the majority of IHC payments, then this will derail the practice of pathology significantly. If pathologists aren't reimbursed for IHC use such as those delineated by LADoc, then we won't be able to give accurate diagnoses!!

It won't matter once we're all employees.
 
IHC usage will really go down when fee for service goes away. Everyone will be fighting for pie and ordering a lot of IHC will not be tolerated.
 
As a quality issue, CMS is requiring that all non-small cell lung cancer biopsies state whether it is squam or adeno or large cell etc.... Not uncommonly that requires a panel of IHC, so Palmetto and their equivalents saying they will only pay for 2 goes against that quality issue.

Years ago the Feds said that they would let the legal community deal with any quality of care issues. They DO NOT CARE.
 
Or IHC will get so cheap no one will care if you order 1,000 of them on every case.
 
The operative word here is LCD. Your intermediary on the west coast would be Noridian and they’re now putting the clamp down, probably related to ICD-10 going online and the billing effects are just being realized by many groups. Read: lower monthly revenues anyone?

We are still getting reimbursed for H.P’s, PIN-4’s etc. for now, but who knows how long this may last. Besides weren’t you doing something else on prostates so you could cash in by other means….?

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.


The pendulum has already begun to swing the other way folks, we will be the ones suffering from the past transgressions of our greedy predecessors. Even the remote locales that are seemingly protected from the reach of the corporate/legislative downsizers and consolidators will not be safe. Going to places like Texarkana, AR won’t cut it anymore. There will be no hills to run to…
 
There will be no hills to run to…

Labcorp came across the sea
He brought us pain and misery
He killed our reimbursement killed our creed
He took our specimens for his own need

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