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Prostate Biopsy Reimbursement Cut 70%+

Discussion in 'Pathology' started by LADoc00, 08.23.12.

  1. LADoc00

    LADoc00 Best Job I Ever Had.

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    Yeah I know there is another thread on this but I have just sprung into action on my emergency alert that this IS going into effect...:scared:

    On August 7, 2012, Palmetto GBA, a Medicare contractor, issued a policy update entitled “Prostate Biopsy Coding/Billing Guidelines." This Palmetto policy references a National Correct Coding Initiative (NCCI) update that was published in January 2012, and appears to be the first instance of a Medicare contractor confirming its adoption of the January 2012 NCCI update.

    The January 2012 NCCI update provides that:

    “HCPCS Codes G0416-G0419 describes surgical pathology, including gross and microscopic examination, or prostate needle biopsies from a saturation biopsy sampling procedure. CMS requires that these codes rather than CPT Code 88305 be utilized only if the number of separately identified needle biopsy specimens is five or more. Surgical pathology on four or fewer prostate needle biopsy specimens should be reported with CPT Code 88305 with the unit of service corresponding to the number of separately identified biopsy specimens.”

    When this January 2012 NCCI update appeared, there was no publication by CMS or any of the Medicare contractors confirming its general adoption by the Medicare program. There has been confusion as to whether NCCI intended the G codes to be utilized only where the biopsies were collected from a saturation biopsy technique, or regardless of the collection methodology. NCCI’s medical director has informed some private sources that the G codes should be used any time there are five or more prostate biopsy specimens, regardless of collection methodology. The August 7, 2012 Palmetto GBA policy adopts the NCCI update, explaining that the number of prostate biopsy specimens (regardless of collection technique) that can be reported with CPT Code 88305 is limited to four units per case, and the evaluation of five or more prostate biopsies must be reported using the G codes.

    It will be important for providers in jurisdictions covered by Palmetto GBA to begin billing and collecting in accordance with this policy update. Providers in other Medicare jurisdictions may wish to confirm with their own Medicare contractors as to each contractor’s policy with respect to the coding of prostate biopsies. As of August 15, 2012, it does not appear as though any other Medicare contractor has published a specific policy on the issue.


    The Medicare prostate biopsies would be billed as follows:
    · 1 up to 4 prostate biopsies would be billed with an 88305 (x the appropriate number up to 4 in a single case, if there are five or more in a single case you would bill with the appropriate HCPCS code see below)

    · 5 to 20 prostate biopsies - G0416 (50-70%+ Reduction in Payment to Pathologist)
    · 21 to 40 prostate biopsies - G0417

    · 41 to 60 prostate biopsies - G0418

    · 60 or greater prostate biopsies - G0419
  2. caffeinegirl

    caffeinegirl

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    This just sucks! Previously the coding was saturation biopsies (perineal approach under general anesthesia) and now this'll pertain to all prostate biopsies (including outpatient).
    But the actual written guidelines pertain to the saturation biopsies only. The "word of mouth" by the director is that this applies to all biopsies. Don't know which one to follow? I'd rather follow the written word....
    Last edited: 08.23.12
  3. NuckingFuts

    NuckingFuts

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    Wow :eek:
  4. LADoc00

    LADoc00 Best Job I Ever Had.

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    Expect some serious firings of jr. pathologists as groups unload this business as fast as they can...similar to the flow cytometry cut (that was even bigger) about 7-8 years ago.
  5. NuckingFuts

    NuckingFuts

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    Completely agree.

    Such bullsh*t, but this is our new reality.
  6. mlw03

    mlw03 Senior Member

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    Please excuse my ignorance, but are you saying pathology groups will decline this kind of business in the future? Ie, telling a group of urologists we won't accept these specimens because the reimbursement isn't worth our time? Won't the urologists retaliate by finding another group for all their business, including the bladder and kidney stuff?
  7. LADoc00

    LADoc00 Best Job I Ever Had.

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    NO.
    Currently the model is basically (with some variation from place to place):
    1.) Get outpatient contract to do work with large urology group. Typically this involves a fee split with the urology group.
    2.) Hire jr. pathologist to cover hospital work/call and read out the prostates, often in or near the uro offices (so call this offsite A).

    If said jr. pathologist was hauling in 300 bucks for a prostate kit to his group after the split with Uros, he is now hauling in around 90 bucks.

    If the Pathology group was floating his salary on a yield of say 200K from doing this, that yield is now sub100, meaning they cant pay that jr. guys salary anymore. Jettison business line/jr. pathologist or both.

    The outpatient business then reverts back to Bostwick etc. meaning in the end, the Big Fish you all think will be hurt by this, will in fact be helped.

    Ironic, isnt it?
  8. schrute

    schrute RoyalCrownChinpokoMaster

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    Perhaps it's just my training location (though I'm at one of the larger GU sites in the country), but we generally never receive biopsies from >4 quadrants anyway... eg. right base, right apex, left base, left apex...with 1 to 4 cores per quadrant.

    88305x4 is our standard billing.

    I've never seen more than upwards of 6 or so sites...what protocol is being followed that allows for 21-40, let alone 41-60, biopsies?

    Is each core being submitted in a separate container?

    ...ok I realize that's done some places--eg. Hopkins--but I wasn't aware saturation sampling was so common.
    Last edited: 08.23.12
  9. Unty

    Unty New Member

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    So you are saying the decreased reimbursement for prostates will be reflected in the lower salary paid to the jr. pathologist. The group will not be able to pay the jr. pathologist as much as before the cut. So, jr pathologist will either have to 1) accept the pay cut which most likely he/she won't or 2) leave. So groups will no longer be able to hire a pathologist to read the prostates, so the biopsies will end up going to a Bostwick type of lab. is this what you are saying? If so, I guess the big shark always wins in the end.
  10. LADoc00

    LADoc00 Best Job I Ever Had.

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    Oh. In the span of 2 hours of panic, my operative within the system has uncovered the "work around" for this new change...muhahahahaha

    Disaster averted for LADOC.
  11. univlad

    univlad Member

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    What is the work around?
  12. pathstudent

    pathstudent Sound Kapital

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    Fee splitting is lame. The urologist ain't giving 50% of his reimbursement to the family practice doc for the patient.
  13. yaah

    yaah Boring Administrator

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    Most of our submissions are 6 sites (2 cores per site).

    Won't change our practice or billing a ton. Definitely more of a blow to in office labs and reference labs.

    It doesn't seem to be a 50-70% cut unless you are truly billing AND COLLECTING for 88305 x 16-20 at present.
  14. WEBB PINKERTON

    WEBB PINKERTON

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    I dont understand how it helps Bostwick unless the in-office lab trend slows down dramatically because of this. But that is no guarantee they will send to them. The urologists in my town use Dianon I believe. Bostwick isnt exactly doing well right now. They have closed labs in many locations and I thought I read they got bought by someone similar to Bain Capital. Their Gynecor division really tried hard to land some accounts where I am at but they failed miserably once patients starting getting billed for those tao brushings. Gynecor sure is a great name for a lab by the way.
  15. pathstudent

    pathstudent Sound Kapital

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    And this ties into many other discussions about why pathology is a reeling specialty. We are fighting amongst ourselves to give up our professional reimbursement to urologists and gastroenterologists.

    It's really pathetic. If we had cojones, no pathologist would do it.

    This is what you have to look forward to sitting in a urologist office signing out prostate biopsies for 10 cents on the dollar while the urologists keeps 60 cents and ladoc keeps the other 30.

    There was a day not to long ago where pathologists got 100 cents of the professional and often even 100 cents of the global.

    Or you can stay in academics and be a clinical instructor or assistant professor and make 80k up to 140 (if you are super super lucky)
    Last edited: 08.23.12
  16. NuckingFuts

    NuckingFuts

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    Wow. It's amazing how some of the textual diarrhea you smear on these threads in your matter-of-fact manner can be taken seriously by unsuspecting readers.

    Get a clue.
  17. 2121115

    2121115

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    Except he is not lying about that.

    I know several "junior attendings" at well known academic places that made 120-135K. Even a few "instructors" who made 80-90K.
  18. LADoc00

    LADoc00 Best Job I Ever Had.

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    Do your homework on the issue. Im not going to post the solution here. And no one else PM me through the site, please!

    Posting things on the internet draws attention to it, unwanted attention.

    I will say this, if Urology groups as SDN posters suggest are getting only 4 cores, then I can say for certain they are missing a huge number of early CAs. That is seriously sub-accepted standard of care (directed to Schrute) even in many socialized medicine countries. Just FYI.

    I have done my homework on the issue and optimal biopsy sampling may even be over 12, more in the 16-18 range.

    The mapping ie 2 containers vs. 12 containers is debatable but the rational from the treatment side is very very strong for some clinicians and I support them in that.

    ZAP-70/CD38 would be analogous situation, some clinicians swear by using this information but many hematologists think it adds nothing. Who is to say who is right.

    OncotypeDX, molecular monitoring of HCV, many molecular tests being ordered...all of this falls into the category of "Do we really need it?"

    You can debate it, that is fine. It doesnt help to come onto SDN and post 6 cores or 12 cores or 18 cores is a "scam" without doing any research whatsoever into the matter without backing that up with some information.

    Just because your podunk local urology group submits 2 containers on every case doesnt at all mean that is the right way to do it!

    End of soap box.
  19. LADoc00

    LADoc00 Best Job I Ever Had.

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    I will "admit" having dated an attending as a resident;)...she made exactly 80K before overtime and extra shifts. Her parents though were quite wealthy so it was immaterial. I actually think that is case with many academic physicians. They self select into academics for reasons other than $ where the student loan/hard scrabble types make their way as quickly as they can into the private scene.
  20. Kunu

    Kunu

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    This is correct. I think they got this right. >6 biopsies is BS and its being done for bilking the system/profit not for medical benefit. Its about time they caught up with the immoral clowns submitting 12 one core biopsies from "Left apex, mid upper outer"
  21. 2121115

    2121115

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    At my training program, I didn't know any academic attending who wasn't married to another physician or high end executive-type. If your spouse makes 300K per year that is all well and good, but don't act high and mighty about academics "not being in it for the money" when the rest of us have to go into private practice in order to have the same lifestyle as you. It is easy to make 120K and do "research" when you are going to live in a $$$ house and your kids are going to attend expensive private schools regardless.
  22. schrute

    schrute RoyalCrownChinpokoMaster

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    I didn't say 4 cores, I said 4 sites/quadrants. But I mispoke on that even...we generally do 8 sites in house, with ~2 per site, so generally >16 cores. (though our VA generally is only 2-3cores x 4 quadrants)

    That still may be less that what some claim is "optimal", though I don't think there's definitive data on what actually constitutes "optimal", and even if there were, it would be a constantly changing target like everything else in medicine depending on the current literature.

    It's no less work to look at 40 cores on 20 slides than 40 cores on 40 slides, and in that sense the rationale to cut reimbursement after 4 cores is financially enfuriating from the path side [similar to it being no easier to look at 5 frozens submitted separately vs 1 specimen with a 5-part frozen (88331x5 -vs- 88331x1 plus 88332x4)] but a cost-cutting measure from the payer/Medicare side.

    I'd LIKE to think that I'd rather have them do crap like this than do a blanket cut on the 88305, but the 88305 cut is inevitable so that doesn't help.
  23. LADoc00

    LADoc00 Best Job I Ever Had.

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    Dude, watch yourself. That's pretty inflammatory and completely uninformed.

    Also, most of the "immoral clowns" are in academics overtraining the Pathology field with trainees destined to be either unemployed or working in slave like arrangements with said Urologists...

    The ROOT CAUSE of almost of this crap is overtraining. An over abundance of Pathologists is what encouraged Urologists to do this to begin with. The culture of Pathology itself is sick, aside from what shenanigans the Government cutters come up with.
  24. schrute

    schrute RoyalCrownChinpokoMaster

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    from the Jan 1 update:

    "10. HCPCS codes G0416-G0419 describe surgical pathology, including gross and microscopic examination, of prostate needle biopsies from a saturation biopsy sampling procedure. CMS requires that these codes rather than CPT code 88305 be utilized to report surgical pathology on prostate needle biopsy specimens only if the number of separately identified needle biopsy specimens is five or more. Surgical pathology on four or fewer prostate needle biopsy specimens should be reported with CPT code 88305 with the unit of service corresponding to the number of separately identified biopsy specimens. "


    Despite it discussing the number of cores/biopsies, it's discussing it in reference to the saturation sampling procedure...so is Palmetto GBA just choosingn to interpret that to include TRUS biopsies?

    Seems open to interp and needs a further explanation from CMS:

    https://www.encoderpro.com/epro/common/medicare/cci_policy_narratives.pdf
  25. NuckingFuts

    NuckingFuts

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    And I personally know 3 folks who started at 200k, as juniors straight out of fellowship, in academics.

    My point was, people ought to do their homework prior to posting utter garbage in such a manner that outsiders would interpret as being fact. -Of course, said readers also ought to be able to judge that said garbage is a matter of opinion.

    Whatever.
  26. pathstudent

    pathstudent Sound Kapital

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    Maybe it varies by region. Buy IME if you are a entry level assistant prof a salary of 150k would be a good deal. Maybe dermpaths get more.

    But to get back to the topic. I am just glad they didn't to it across the board on 88305s. I was concerned they might. Paying 6000 for a pathology bill to diagnose prostate cancer is basically fleecing the American public and there is no way the CMS could let that continue.
    Last edited: 08.24.12
  27. lipomas

    lipomas

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    The root cause is not overtraining. The root cause is that the reimbursement scheme leads itself to be manipulated for profit. Wherever there is a chance for profit, someone will fill that gap. What encouraged the urologists was not pathologist availability but profit availability. If pathologists were harder find they would just offer slightly more until they found someone willing to take their cases.

    Note that I am not saying there isn't overtraining. There are too many path residencies. But if you think that having a pathologist shortage would magically solve the problem of pod labs think again. A shortage of pathologists would mostly harm smaller groups who would find it harder to attract good candidates. It would probably also hurt academic centers. It would not hurt reference labs who provide a good lifestyle and less stress. They would have to pay more, to be sure, but I doubt it would be that much more.

    Heck, smaller groups in rural areas already have trouble attracting good candidates. The good ones they manage to attract don't want to be there and spend their entire time looking for a better job. So they end up settling.

    The perpetuation of this fallacy on this forum continues to annoy me. This is magical thinking, pure and simple. You can make your argument without resorting to fallacies.
  28. lipomas

    lipomas

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    Um yeah, wait a tick.

    This is for "saturation" biopsies, as said above. "Saturation biopsies" and TRUS biopsies are not the same thing. Saturation biopsies are usually done under general anesthesia and are only 5% or less of overall prostate biopsies.
  29. 2121115

    2121115

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    I've never even seen a saturation biopsy actually. I'm not really worried about this.
  30. pathstudent

    pathstudent Sound Kapital

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    See my thread. My billing company said Medicare has clarified this will apply to all prostate biopsies. They have instructed us to start using it.
  31. schrute

    schrute RoyalCrownChinpokoMaster

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    I would get that in writing. The language from the Jan 1 update is vague, or at a minimum confusing. The preface of the paragraph on this coding switch references saturation biopsies, not TRUS biopsie, hence the subsequent talk of "prostate biopsies" is in reference to sat bxs.
  32. yaah

    yaah Boring Administrator

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    They are much less than 5% of our total biopsies. Some places they are higher, it depends on local practices and the urologist. I have seen them used for patients who have had multiple negative biopsies with a markedly elevated PSA, and for patients with tiny foci for whom they are trying to determine whether it really is a tiny focus. But even for those indications it isn't that much more helpful.
  33. pathstudent

    pathstudent Sound Kapital

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    Again Medicare Clarified it in a message in the last few days. And said it applies to standard trus prostate biopsies too.
  34. pathstudent

    pathstudent Sound Kapital

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    Do you bill for full professional component or do you have to split the fee with the urologist?
  35. yaah

    yaah Boring Administrator

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    The urologists don't bill for any pathology where we are.
  36. pathstudent

    pathstudent Sound Kapital

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    That's totally rare and totally awesome.
  37. 2121115

    2121115

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    Yes, it is in my experience.

    There is a lot of geographic variation in these things, which may influence pathologists' perception of how good/bad things are out there.

    Where I am there is no urology group in town that doesn't bill the pathology. Also there are gyn's billing for path, GIs, and derms too. We have not seen a prostate needle core biopsy in several years because we weren't willing to "go that low", and someone else was. Ultra cut throat stuff.
  38. KeratinPearls

    KeratinPearls

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    The first step in the right direction is making these in office labs illegal. I don't think the number of residency programs will ever be decreased though.
  39. Kunu

    Kunu

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    BS there is NO reason to put each separate core in its own container other than FRAUD.
    It doesnt matter one flip if there is 5% more cancer picked up in one core distinct from another ipsilateral fragment. Our Urologists put two cores per sector from Apex, base, and mid. So thats six blocks. Thats more than adequate. Please explain to me the medical benefit derived from separating the two of that into 12 containers. Its exactly this kind of immoral CRAP that is hemorrhaging our healthcare pot and induces reimbursement overreaction schemes that make life difficult for people making an honest living.
  40. pathstudent

    pathstudent Sound Kapital

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    I tend to agree with you. So what if you put all biopsies in one container and only charge the patient an 88305x1. Let's say 2 of the 12 have cancer in ten percent of the biopsy. Who cares if you know that one was from the right mid apex and the other was left mid apex. Prostate cancer is staged by prostatectomy not biopsy. I have seen a lot of cases where the patient goes to radical prostacectomy with only cancer in <5% in one biopsy. Who cares which 1/12th of the prostate was in. I'm the first to admit that i am not the most knowledgable person. Maybe there is some literature based decision making flow chart based on how the biopsies turn out, but I am not aware of it. And all of this is compounded by the recent reports that prostate cancer is heavily over treated to begin with.
    Last edited: 08.27.12
  41. Kunu

    Kunu

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    No there is some benefit to a distinction of bilateral disease and/or some value to approximate disease extent to separate some sectors to facilitate management plans but 10+ fragments separated is stupid.
  42. BrainPathology

    BrainPathology of Gnomeregon.

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    You HAVE to do it this way so that when they do prostate sparing oncologic surgery they know what quadrant to resect.

    (For those of you who miss sarcasm constantly ALERT ALERT!!!)
  43. WEBB PINKERTON

    WEBB PINKERTON

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    Client billing is worse than in-office labs. Better fight that first.
  44. LADoc00

    LADoc00 Best Job I Ever Had.

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    this is false.
  45. yaah

    yaah Boring Administrator

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  46. pathstudent

    pathstudent Sound Kapital

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    Nope. Thats not what i am hearing.
  47. 2121115

    2121115

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  48. pathstudent

    pathstudent Sound Kapital

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    Thanks.

    Man this is going to be a rough time for those of us just getting started in the last few years.

    Our Medicare Tax is going up to fund ACA. Our revenue on TC will be going down as part of ACA. And soon our income taxes will go up because we are the "bad people" whose success was given to us and not earned and so we should be eager to participate in wealth redistribution. And we will continue to see CMS ratchet back our fees and who is going to care because we are just a bunch of rich doctors anyway.

    Heard them say at the DNC that healthcare costs have gone up 300% over inflation the last few years. Well talking to my colleagues pathology incomes have been stable and actually declined a bit over the last 20 years. So I don't think we are the problem.
  49. WEBB PINKERTON

    WEBB PINKERTON

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    This really isnt that big of a deal and wont affect too many people. In-office labs are the ones getting pushed over the cliff and Plandowski knows it.


    I am suprised anyone watched the DNC. They accuse republicans of waging a war on women yet they had a tribute to Teddy Kennedy, a man that actually killed a woman. Got a good laugh out of that.
  50. mikesheree

    mikesheree

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    Hey, like former ultra lib house speaker Gephardt said, you "hit life's lottery".

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