New single G code for prostate

[pathstudent]

Read in the CAP magazine today that cms is proposing a single g code for prostate biopsies regardless of how many containers you put them in.

About time. The 12 sector biopsy of the prostate has to be one of the biggest unethical scams of all time. If this goes through and is adopted by insurance, I'll bet the house that we just go back to doing just multiple left and right biopsies. All the scheisters who claimed the 12 sector biopsy was superior for detecting cancer (oh and by the way increases the cost by six times over doing just multiple left and right biopsies) will disappear.

No one has done more harm to pathology reimbursement than urologists and their pathologists. It is nice to see cms single them out.

---

Members don't see this ad.

 

[coroner]

Well, I guess it's time to say goodbye to charging an 88305 x 12 + 88342 x 36 for the triple cocktail. I could see my boss complaining how is he going to be able to pay the utility bill and put the kids thru college...

The American Urologic Association had a bulletin that this proposal was in the pipeline back in January.
http://www.auanet.org/publications/hpbrief/view.cfm?i=2857&a=5646

As far as the necessity of the 12 part biopsy, you're right: there is literature stating it does not increase detection

http://www.ncbi.nlm.nih.gov/pubmed/20817273
http://www.sciencedirect.com/science/article/pii/S0022534705673673

My only concern is this isn't a gateway for CMS to start running rampant and issuing G codes all over the place for anything they deem as overkill. This already occurred for the 88342's and it could be a slippery slope...

 

[pathstudent]

Don't forget making a thin prep on each fluid that the biopsy comes in 88112x12. Might be a cancer cell that fell off one of the cores.

No from what I read, there will be one single g code no matter how many biopsies are done or how many containers you them in. At least it is on the table for 2015. If so I bet we go back to doing left and right and no one will die or not get the same treatment options as they now have if prostate cancer involves 5% of one core on the right and 10% of one core on the left instead of 5% on right mid base and 10% on left lateral base.

Gi and derm could be targeted too. An 88305 for a bone marrow biopsy or an encor breast biopsy or kidney biopsy seems undervalued to me already. I think a reasonable person would see that, but you never know.

 

[malchik]

An 88305 for a bone marrow biopsy or an encor breast biopsy or kidney biopsy seems undervalued to me already. I think a reasonable person would see that, but you never know.

But is there any incentive for CMS to increase reimbursement for kidneys or marrows? They're looking for things to cut

 

[WEBB PINKERTON]

Don't forget making a thin prep on each fluid that the biopsy comes in 88112x12. Might be a cancer cell that fell off one of the cores.

No from what I read, there will be one single g code no matter how many biopsies are done or how many containers you them in. At least it is on the table for 2015. If so I bet we go back to doing left and right and no one will die or not get the same treatment options as they now have if prostate cancer involves 5% of one core on the right and 10% of one core on the left instead of 5% on right mid base and 10% on left lateral base.

Gi and derm could be targeted too. An 88305 for a bone marrow biopsy or an encor breast biopsy or kidney biopsy seems undervalued to me already. I think a reasonable person would see that, but you never know.

My god, do you really know of labs spinning down residual formalin and making cytology preps? Ridiculous. They did slash 88112 reimbursement by 33 percent this year. Must have been more common than I thought.

 

[2021Doctor]

My god, do you really know of labs spinning down residual formalin and making cytology preps?

Yes.

 

[LoaLoa]

My god, do you really know of labs spinning down residual formalin and making cytology preps? Ridiculous. They did slash 88112 reimbursement by 33 percent this year. Must have been more common than I thought.

Yes.

 

[path24]

Hopefully it stays with prostate....otherwise we are completely screwed.

Instead of going after abuse, they kill us all. Doesn't look good for the future of this profession.

 

[yaah]

People who want to abuse the system to make money will always find a way. Once they can't find a way anymore, they exit the business. Maybe they'll start doing non-prostate biopsies at the same time so they can bill them separately. "Rectal fascia" to evaluate for invasion. "Seminal vesicle" (which is not prostate!). Bladder. Fibromuscular stroma (NOT PROSTATE!). Whatever the number of sites that allows you to increase to the next level of G code will suddenly become much more common. What will it be, 15 sites?

Having a single code that is equivalent to 5-6 88305s is not the end of the world. A lot of labs only receive 6 specimens now. Still 12 cores, but two per container x 6.

 

[univlad]

What is the proposed reimbursment for the new G code? In dollars, how many 88305's does it equal?
Will we see the urologists decrease to that number of biopsies?

 

[pathstudent]

If it is equivalent to 6 Medicare 88305s that would mean about 420 for processing and interpreting no matter how many cores or containers there are. Seems reasonable enough but is a huge reduction from 3 years ago when it would have been about 1300 for processing and interpreting 12 biopsies placed in twelve containers.

I trained at a huge gu place and in order to keep the cost low for the patient the head of GU pathology just had the urologists place the 12 biopsies into right and left containers which means it only cost the patient or goverment 88305x2 which back then probably meant about 240 total cost.

 

[yaah]

I had thought it was equivalent to 5 88305s, but I may be wrong. I think it's in flux, it's a proposal. Being challenged by lots of people I suspect there will be some modification, but who knows.

Should bear in mind that many places currently do bill and process 6 specimens in a standard 12 core biopsy, so the change would not be as significant for those groups.

 

[2121115]

We process all cores in two blocks, right and left. Usually 6 cores per block. We only bill 2 88305s now, so getting reimbursed the equivalent of 5 or 6 88305s for the G code is going to be very nice for our group. Can't wait for this to happen.

 

[LADoc00]

As far as the necessity of the 12 part biopsy, you're right: there is literature stating it does not increase detection

http://www.ncbi.nlm.nih.gov/pubmed/20817273
http://www.sciencedirect.com/science/article/pii/S0022534705673673

These supposed articles are patent B.S. and you can prove the exact OPPOSITE hypothesis with numerous other citations from more reputable sources.

If you are seriously gonna quote evidence from US Federal VA system (ie the first article) which is more corrupt than the NYC trash collection business you do not deserve any recognition as an educated physician...

Just stop and go away.

More cores CLEARLY increase detection and I dont need to cite fabricated political pseudoscience.

Detection increases early identification.

Early identification increases cost spent on the disease.

Politicians dont like money that isnt spent on breast cancer or other politicized pathologic processes hence the crackdown.

This has nothing to do with healthcare and everything to do with control.

That is all.

 

[pathstudent]

These supposed articles are patent B.S. and you can prove the exact OPPOSITE hypothesis with numerous other citations from more reputable sources.

If you are seriously gonna quote evidence from US Federal VA system (ie the first article) which is more corrupt than the NYC trash collection business you do not deserve any recognition as an educated physician...

Just stop and go away.

More cores CLEARLY increase detection and I dont need to cite fabricated political pseudoscience.

Detection increases early identification.

Early identification increases cost spent on the disease.

Politicians dont like money that isnt spent on breast cancer or other politicized pathologic processes hence the crackdown.

This has nothing to do with healthcare and everything to do with control.

That is all.

Of course more cores increase detection. But they don't need to be put in separate containers and billed separately. A good tech could line up 6 and level them out so you wouldn't miss a thing. Also there is lots of evidence that you are detecting cancers that don't need to be treated. You need to do 50 prostatectomies to prevent one mortality. In other word the other 49 were of no benefit and perhaps made the men incontent or unable to get hard.

 

[yaah]

These supposed articles are patent B.S. and you can prove the exact OPPOSITE hypothesis with numerous other citations from more reputable sources.

If you are seriously gonna quote evidence from US Federal VA system (ie the first article) which is more corrupt than the NYC trash collection business you do not deserve any recognition as an educated physician...

Just stop and go away.

More cores CLEARLY increase detection and I dont need to cite fabricated political pseudoscience.

Detection increases early identification.

Early identification increases cost spent on the disease.

Politicians dont like money that isnt spent on breast cancer or other politicized pathologic processes hence the crackdown.

This has nothing to do with healthcare and everything to do with control.

That is all.

Actually, it has a lot to do with health care.

As stated above, most people doing "6 specimens" are actually doing 12 cores (or more). So the only difference between 12 specimen and 6 specimen is 88305x6.

More cores clearly increase detection but whether they increase detection of "significant" cancer is the more important question. While a lot of people would prefer their small low grade cancer be detected, whether they treat it or not, many others don't want it detected if it isn't going to kill them.

The crackdown has everything to do with abuse of the system. It's more about controlling the billing process than controlling treatment.

The far, far bigger impact on treatment and diagnosis from prostate cancer has come from the USPTF guidelines. There is going to be a lot more advanced prostate cancer diagnosis over the next few decades because of this. Whether this harms/kills more men or not is again the real question, but advanced prostate cancer is far more problematic treatment-wise and prognosis-wise than non-advanced. The screening guidelines are also far more political than the attack on the billing codes.

 

[LADoc00]

The government knows WHO the abusers are. They have this data. But they choose not to go after them because under the guise of going after the abusers they can attack the reimbursement of EVERYONE.

The names and stories of the abusers are being leaked in coordinated fashion to news outlets as an orchestrated campaign to attack Medicare reimbursement for all doctors and hospitals.

The abusers themselves are given free reign for years if not decades so they might produce a more satisfying and titillating news piece they can foist onto a brain dead American populace.

Prostate biopsies are only the beginning as I fully expect them to cap GI biopsies, skin biopsies and all sorts of mutli-part specimens that are now rightfully submitted to pathology as separate units of service.

Do the math on how many specimens your group bills for vs. how many cases are accessioned.

The reduction is coming and it will be epic.

That is all.

 

[BlondeDocteur]

That is a little... tinfoil hat/ black helicopters for me. Loopholes are found and the unethical profit until it becomes intolerable, and the wheels of regulatory change start grinding.

 

[yaah]

Skin biopsies have been marked as potential for reclassification for many years now, and it still hasn't happened. It eventually will, but obviously there is a lot of resistance to it.