An actual GI biopsy question...

[cmz]

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There is this one group of GI that do A LOT of biopsies, especially gastric biopsies. I am not a GI-fellowship trained pathologist, but I do read stuff and try to keep abreast of current guidelines, etc. This group tends to ALWAYS do at least four gastric biopsies (body, fundus, antrum, and incisura) on every single patient. I have read their endoscopic notes and there is always a vague mention of "mild diffuse gastritis" no matter what.

In normal practice, I usually got these types of biopsies (in most cases) when the patient was suspected of having an autoimmune process or maybe for mapping IM. If the question is simply to look for HP, why can't this question be asked with maybe two sets of biopsies? I have my deep suspicion as to why it is being done, but I am trying to see if there is actually any reason why it would be important to know if a patchy process like HP infection needs to be teased out by assigning each biopsy as such. I guess they are taking the Sydney guidelines to the Nth degree? It just seems overkill...

 

[Pathofourlives]

I’ve worked for a GI private practice and heard a lot about others as I’m GI trained. Many of these practices pad the bill with unnecessary biopsies. My previous practice even asked me if it was a potential red flag to payors that they took 10-12 biopsies (including uppers and lowers) per patient. I presume because they were getting kicked back claims. Does this practice also do the shady AB/PAS on every esophagus and duodenum?

 

[cmz]

I don't think they do erroneous AB/PAS on every esophagus/duodenum, but I don't work for them or see biopsies that go to their lab. I just catch the stray biopsies they have to perform at the hospital ASC just because of the patient population requiring a higher level of acuity just in case.

I just find it a bit concerning regarding the number of samples being taken. If I don't see bugs on H&E and I see more than the usual amount of inflammation, I feel obligated to do HP IHC. I could have probably evaluated all of these biopsies in two blocks (or hell even one block) because the endoscopist is only giving me a rinky dink single biopsy per jar to begin with and I would have felt better just ordering 1 HP stain at this point. I just want to make sure my own butt is protected (I do a lot of documentation of necessity in my reports as it is).

 

[caffeinegirl]

You are responsible for the biopsies only - not about the number of biopsies taken. That's on the GI doc doing the biopsies. I've been hearing for years that GI biopsies are going to be bundled like prostate biopsies, but it hasn't happened yet. Until it does, you'll still see this happening, especially for those with in-house labs. As a pathologist, as long as you remain in the LCD guidelines, you're covered

 

[cmz]

You are responsible for the biopsies only - not about the number of biopsies taken. That's on the GI doc doing the biopsies. I've been hearing for years that GI biopsies are going to be bundled like prostate biopsies, but it hasn't happened yet. Until it does, you'll still see this happening, especially for those with in-house labs. As a pathologist, as long as you remain in the LCD guidelines, you're covered

Thanks for the information! It is a bit disconcerting to see so many redundant biopsies being taken. It seems it is inevitable that we'll see GI biopsies get bundled. It's not on a sustainable pathway.

 

[KeratinPearls]

Who are the dumba$$es that allow these clinicians to own their own in office lab. Greed and money always corrupts people.

That lawyer Jane Pine Wood did a study where she concluded these in office labs overbiopsy. I guess nothing ever came out of it.

 

[caffeinegirl]

Who are the dumba$$es that allow these clinicians to own their own in office lab. Greed and money always corrupts people.

That lawyer Jane Pine Wood did a study where she concluded these in office labs overbiopsy. I guess nothing ever came out of it.

Just shows you the strength of the GI lobby compared to pathology. ASCP and CAP are small potatoes compared to the IM subspecialties.

 

[HeyDalaron]

Just shows you the strength of the GI lobby compared to pathology. ASCP and CAP are small potatoes compared to the IM subspecialties.

I wouldn't say they're small potatoes as much as I would proffer that the aim, at least of the CAP, is to propagate their proficiency testing business, which is the most profitable portion of their enterprise. Membership makes up only a fraction of CAP's income. The oversupply, the biggest problem in the field of pathology, massively benefits corporate labs, who are the main customer of the CAP. In-house labs can exist as a side effect of this.

 

[KeratinPearls]

I wouldn't say they're small potatoes as much as I would proffer that the aim, at least of the CAP, is to propagate their proficiency testing business, which is the most profitable portion of their enterprise. Membership makes up only a fraction of CAP's income. The oversupply, the biggest problem in the field of pathology, massively benefits corporate labs, who are the main customer of the CAP. In-house labs can exist as a side effect of this.

I talked with a pathologist who worked for the previous CAP president and she told me she got 4 weeks of vacation and sick days were taken from vacation days. SEPA labs. Look up the owner. She worked at that Jacksonville Baptist hospital location.

Sold to PathGroup in 2019 for probably tens to hundred million.

How can you trust these clowns to be an advocate for pathologists?

Oversupply=nice supply of pathologists to labs at low wages.

 

[caffeinegirl]

Yeah - I was just mentioning the size of the lobby - not the actual quality of the organization. CAP has been notorious for not really lobbying for pathologists' interests for years, and does mostly exist as a proficiency testing business. It's very different from other subspecialties - who do focus on policies and workforce (to actually represent the workforce, rather than manipulating it for their own profit)

 

[Med Director New England]

Who are the dumba$$es that allow these clinicians to own their own in office lab. Greed and money always corrupts people.

That lawyer Jane Pine Wood did a study where she concluded these in office labs overbiopsy. I guess nothing ever came out of it.

Her study was impactful
Note it only included extended core prostate biopsies.
And now Extended core prostate biopsies have a unique bill code that removes the financial motivation to send more jars (same reimbursement if 2,4,6,12 or more jars are sent)

 

[cmz]

It is rather disappointing that in-office labs are still a "thing." These labs can't exist without the aid of a pathologist, and, in most cases, they seem to pay pretty well (at least in my area). I am sure the compensation pales in comparison to what the pathologist should be earning, but you have to resign yourself to the fact that we have little to no control of our referral sources. It's not a game you're going to win.

I wonder how the pathology job market would react if GI biopsies suddenly could only be billed as bundled payments (e.g. upper GI biopsy series and lower GI biopsy series). Fortunately or unfortunately (depends on how you look at things), my practice is humbled by the fact that our revenue steam consists of very little GI biopsies so this change would not affect us much. This change would definitely pose a huge threat to the in-office labs that seem to rely on these expanded biopsy panels hunting for the ever elusive H. pylori (see above). What what was once 88305 x 4, 88342-59 x 4 could now become 88305 x 1, 88342 x 1 (or whatever CPT code they might use to bundle 88305/88342 combo) at best. Everyone has mentioned bundling but is this a realistic possibility of happening in the near future? How long did it take for CMS to make the change to prostate saturation biopsies to one bundled G code?

 

[KeratinPearls]

My practice is 50% GI. If it gets bundled our revenue and my salary will get hit hard. One guy on Reddit mentioned his practice has 80% GI.

 

[cmz]

My practice is 50% GI. If it gets bundled our revenue and my salary will get hit hard. One guy on Reddit mentioned his practice has 80% GI.

Make hay while the sun shines...

 

[WEBB PINKERTON]

Who are the dumba$$es that allow these clinicians to own their own in office lab. Greed and money always corrupts people.

That lawyer Jane Pine Wood did a study where she concluded these in office labs overbiopsy. I guess nothing ever came out of it.

I always thought it was funny JPW went to work for bioreference labs. They were notorious for unecessary testing and lead to the NEJ medicine article called the 1000 dollar pap test. Bio bit the dust in recent years. You could see it coming.

GI will be a PE victim and the biopsies heading to the PE lab, if they arent already. in office labs are toast.

 

[cmz]

I always thought it was funny JPW went to work for bioreference labs. They were notorious for unecessary testing and lead to the NEJ medicine article called the 1000 dollar pap test. Bio bit the dust in recent years. You could see it coming.

GI will be a PE victim and the biopsies heading to the PE lab, if they arent already. in office labs are toast.

Bingo. The one big GI group in my area has a "plan" to offload everything to PE in the next couple of years. It'll be a nice added bonus to show that their group of ~9 GI are producing 500-600 bx/day for their lab.