Too much IHC?

[DPath2000]

Hello forum,

Our new group had a question regarding IHC. One of our doctors came across this sample CBR report (attached) and asked me an interesting question.
"In the eyes of Medicare, how much is too much IHC/special stains, in relation to the 88305?" Granted that sample CBR was for GI and it seems like it isn't a punitive document, but it raises the question of what percentage of IHC (in relation to 88305) one would need to be classified (both locally and nationally) as "does not exceed," "higher," and "significantly higher." I do not know much about how Medicare monitors our use of special stains and IHC. Perhaps some people on this forum can provide some insight.

We only order IHC when medically necessary. We do predominantly dermpath so most of our cases are signed based on the H&E. I know pathologists who order Melan-A and SOX10 liberally on pigmented lesions and I am sure other subspecialties order a lot of IHC on their biopsies. Is there some sort of general rule, like a percentage, to stay under, to avoid scrutiny?

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[deleted314957]

I don’t know a percentage but you can be damned sure
that whatever it is you will NOT avoid scrutiny.

 

[Med Director New England]

our group looked at this in two specific settings: The number of Prostate triple stains ordered in extended core prostate biopsies and p16 on cervical biopsies. We found tremendous variation in the group, high IHC utilizers ordered 4-5 x more than lower utilizers. Our group is all employed, RVUs do not factor into salary so no financial motivation to order IHC. This variation seems only related to comfort levels of pathologists, experience, etc.

As to the correct number of IHC/88305 - tough to answer, that would depend a lot on case mix etc. Our group as a whole on average ordered around 1 Triple stain / extended core prostate biopsy (but again with a lot of variation between the individual paths)

When / If any payer audits IHC usage it will be fairly easy to find outliers (and potentially abuse) by looking at claims data. Extremely high IHC usage relative to peers would be a red flag and then some more granular data would be necessarily to confirm that there is indeed abuse and not normal variation. I have heard of some labs ordering IHC on every duodenal biopsy to supposedly increase the sensitivity for detecting celiac, Melanoma panels, etc that sort of non-sense would be easy to find with good claims data. One group getting dinged for this and then the word of mouth rumor spread would quickly stamp out abusive behavior.

If you practice reasonably and orders stains when needed you will be fine. No one will second guess anyone for ordering 10 IHCs to help classify a sarcoma, but if you start doing a reflex type IHC in a setting that is not standard you probably are at risk.

 

[LADoc00]

There is no such thing as in eyes of Medicare how much IHC is too much...there are a dozen variables that would move that needle in one direction or another.

Medicare does respond very very well to whistle blowers though. If you screw someone over and they go to Medicare and claim you are fraudulently over-ultizing, prepare for a RAC audit....

 

[Pathbusiness]

When things go beyond common sense in the name of productivity, audits and lawsuits happen.

 

[yaah]

To me, anything that becomes a "routine" process is a problem unless you can completely justify it. That is, ordering H Pylori on EVERY gastric biopsy, or melanocytic stains on every melanocytic lesion. Justify it for each case and you will have less problems. THere are exceptions, of course, like always ordering hormone receptors on new breast cancers and such. But those are justified if not required. If the clinician is the one demanding you "always do CD3 and CD20 on intestinal biopsies" then that's another story, but it's important to understand and evaluate why this occurring and what education can be provided.

I order a lot of IPOX because the percentage of cases I have that are "unknown mass biopsies" are high. My ipox usage rate on prostate cores and bladders is very low, but it ends up being higher because I see so many lung cores, kidney cores, and lymph node cores and malignant effusions in patients with no known history. Our GI pathologists, for example, have much lower rates of usage than me because they see mostly GI.

 

[deleted314957]

Change my view: Given how liberally clinicians order pan labs (CBC, extended lyres daily) and image after image on every patient, we should be allowed to order as much IHC as we want as well routinely.

Oh, but you see, they’re trying to make a diagnosis. We just abuse the system.

 

[Guest8]

Oh, but you see, they’re trying to make a diagnosis. We just abuse the system.

To be fair, most IM docs aren't getting paid per test they order unless they own their own lab. Actually, WE make money off of all the extraneous blood tests etc they order. But we are the direct beneficiaries of added IHC testing. Sort of apples/oranges.

 

[deleted314957]

To be fair, most IM docs aren't getting paid per test they order unless they own their own lab. Actually, WE make money off of all the extraneous blood tests etc they order. But we are the direct beneficiaries of added IHC testing. Sort of apples/oranges.

Valid point.And I see your point. I’d like to think that my outlook was that the patient was the
beneficiary of the testing I ordered. I never did financial analyses of my cases. I doubt essential
none of us do.

 

[WEBB PINKERTON]

To be fair, most IM docs aren't getting paid per test they order unless they own their own lab. Actually, WE make money off of all the extraneous blood tests etc they order. But we are the direct beneficiaries of added IHC testing. Sort of apples/oranges.

Don't need to own your own lab. Just client bill.

 

[cmz]

I think if someone were to look at my practice, they might say that my group perhaps orders H pylori IHC too liberally. My response is always the same and I have data to back my claims up. I live in an area that is known as the HP capital of the world. Everyone is on PPIs. We don't always see the bugs on H&E and I know that the critters are hiding deep. I've seen countless cases of minimal inflammation with rip roaring HP on IHC. Our clinicians are requesting the IHC themselves and feel slighted if we don't do the stain.

Overall, our group's utilization of IHC is probably within the normal limits of utilization. I think I mentioned this in another thread but my group recently acquired a contract for a local hospital where the former pathologist deferred any case that required IHC for "expert consultation" to a lab that rhymes with a popular TV show. This particular lab ordered anywhere from 15-30 IHC on every case no matter what. This is not an exaggeration. I saw 29 IHC ordered on a pleural fluid cell block on a case that was finally diagnosed with "atypical mesothelial cells present." I mentioned here in another thread that a cervical cone biopsy was sent for consult and it came back with a diagnosis of "CIN III" and 8 IHC were ordered including CD138, CK 5/6 and CK OSCAR. I am not sure what kind of contractual agreement was set up between the lab and the hospital, but this was obviously very fishy. If you ask my what kind of medical director would allow this to continue... I'd have to say that person was probably receiving a little kick back or honestly and truly had no idea how IHC works. This sort of reminds me of that scene in the movie Casino where Robert DeNiro calls out Joe Bob Briggs for either being too stupid to realize he was being taken or was in on the fix to begin with when the slot machines were being robbed.

 

[Guest8]

Don't need to own your own lab. Just client bill.

Luckily I live in a state that doesn't allow that. So I've got that going for me.

 

[yaah]

You can look up your own (and anyone else) utilization here: https://data.cms.gov/utilization-and-payment-explorer

At least, what you billed medicare.