Breast pathology reimbursement issues

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raider

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Why current breast pathology practices must be evaluated. A Susan G. Komen for the Cure white paper: June 2006.
Pathologists, radiologists, and surgeons generally agree that pathologists are not adequately compensated for performing breast pathology. A pathologist who is thorough is likely to lose money, yet a thorough review is needed for diagnostic accuracy. The average stereotactic vacuum-assisted biopsy specimen requires review of slidesfrom approximately 2 to 3 paraffin blocks, whereas a wire-localized surgical breast specimen averages 15 to 20blocks; however, reimbursement is generally not based on the type of specimen reviewed or the complexity of the case.[personal communication, Dr. Ibarra] For example, a breast core biopsy, which requires multiple levels (often 3 to 6) and needs correlation with imaging, is reimbursed at the same rate as seborrheic keratosis, a non-cancerous
skin growth that can be diagnosed with the review of only one slide. This clearly demonstrates the lack of connection between workload and reimbursement and should be particularly concerning given that one condition is potentially fatal while the other is relatively benign. Low rates of reimbursement may also lead to suboptimal review of ductal
carcinoma in situ (DCIS) resections. A DCIS resection may require up to 40 paraffin blocks, and a pathologist needs to examine 100% of the specimen to determine the size and margin status and confirm the absence of occult invasive disease, information crucial to the subsequent treatment decision. This thorough review is time-consuming,
and current reimbursement is not commensurate with the work or materials used. Since the incidence of DCIS is rising, the low reimbursement rate is a major issue.


Oops! This is not important, instead lets talk about transformation and "rounding with clinicians", while other specialities address real issues.


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Good point, but see when the bean counters see something like that, they will not conclude that the breast biopsy is undercompensated but that the SK is overcompensated! And the statement "low rate of reimbursement may also lead to suboptimal review of..." while true is also red meat for a hungry lawyer. So doctor, you didn't think my client's specimen was important enough to devote more time too because you were worried you wouldn't get compensated enough for it? How much money did you make last year doctor? How much does a glass slide and a plastic tissue cassette cost?
 
I've always thought breast cores should be reimbursed better - it isn't like prostate where you get multiple sites. But in general, needle cores of unknown tumors are often a lot of work, it isn't just breast cases.
 
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I've always thought breast cores should be reimbursed better - it isn't like prostate where you get multiple sites. But in general, needle cores of unknown tumors are often a lot of work, it isn't just breast cases.

This is one area that I really wish CMS would address. Pathologists and Urologists have totally expoloited reimbursement to maximize revenue yet have little to know impact on morbidity or mortality. Prostate biopsies could just be put in one container or two containers (right and left) and it would cost insurance companies, patients, and tax-payers (medicare) 1/6th to 1/12th as much. If prostate biopsies are better evaluated by only looking at two cores per slides, then so be it. Only put in two cores per cassette, not per container.

I have seen prostatectomies done when a guy just has cancer in >5% of one out of twelve sites. What difference did it make what sector it is in? It didn't. But it did make the pathologist or urologist 12 times as much money.

Prostate biopsy pathology is the best example of pathologists gaming the system and it has to stop because if it doesn't they will **** up reimbursement to an even greater extent for everything else like lung and breast biopsies.

A prostate biopsy should not cost the patient 1500 for pathology while a breast biopsy costs 120. It is freaking joke.

And just think, things like lymph node biopsies for lymphoma only pay an 88305 while that take 100 times the brain power over looking at a prostate biopsy.
 
These types of issues only tend to come up in academic subspecialist settings where a pathologist only signs out 1 type of specimen (only breast cases for example). However, these pathologists are in academics so they get paid a salary anyway so why should it matter? If they start reimbursing breast biopsies more the academic breast-specialist pathologist will never see one dime of it. It will go to someone else. I don't see why they care so much.
 
My understanding is that CAP is actively involved in CPT coding reimbursement issues. I know they have committees that focus on financial issues such as this, and they spend a lot of time and money with lobbying efforts in Washington. But I guess raider is implying that any agendas other than these, such as transformation, are a waste of time. Maybe? I think there are mixed opinions on this.
 
I don't think there is usually a lot of intraprofession chatter on billing/reimbursement problems because most people think they agree there are billing/reimbursement problems. Realistically there are probably a lot of nuances most people don't consider, especially those on salary or not handling the business side of a private practice.
 
Hmm I wonder what exactly Im doing wrong because Im getting paid fairly well for the time spent.

Will get back to you on this.

88305x1, 88342x4, 88361x4...10minutes max of work.
win.
 
Hmm I wonder what exactly Im doing wrong because Im getting paid fairly well for the time spent.

Will get back to you on this.

88305x1, 88342x4, 88361x4...10minutes max of work.
win.

Well if you are comparing the 88305 part to a Seb K, there is some inequality.
However, I think the better discussion is about the DCIS lumpectomy specimens.
 
Well if you are comparing the 88305 part to a Seb K, there is some inequality.
However, I think the better discussion is about the DCIS lumpectomy specimens.

We cant have everything, I wish Megan Fox was my transcriptionist, but I cant afford her. I agree reimbursement across the board should rise, but I think in the current political climate and due to the fact the US gubberment is broke, the chances are slim.

For starters I would vote all Democrap out of office. :)
 
Hmm I wonder what exactly Im doing wrong because Im getting paid fairly well for the time spent.

Will get back to you on this.

88305x1, 88342x4, 88361x4...10minutes max of work.
win.

What is the 88361 for?

Granted I'm in the military so we only code until it looks passable, but I don't think I've ever coded that/
 
Why current breast pathology practices must be evaluated. A Susan G. Komen for the Cure white paper: June 2006.

Pathologists, radiologists, and surgeons generally agree that pathologists are not adequately compensated for performing breast pathology. A pathologist who is thorough is likely to lose money, yet a thorough review is needed for diagnostic accuracy. The average stereotactic vacuum-assisted biopsy specimen requires review of slidesfrom approximately 2 to 3 paraffin blocks, whereas a wire-localized surgical breast specimen averages 15 to 20blocks; however, reimbursement is generally not based on the type of specimen reviewed or the complexity of the case.[personal communication, Dr. Ibarra] For example, a breast core biopsy, which requires multiple levels (often 3 to 6) and needs correlation with imaging, is reimbursed at the same rate as seborrheic keratosis, a non-cancerous
skin growth that can be diagnosed with the review of only one slide. This clearly demonstrates the lack of connection between workload and reimbursement and should be particularly concerning given that one condition is potentially fatal while the other is relatively benign. Low rates of reimbursement may also lead to suboptimal review of ductal
carcinoma in situ (DCIS) resections. A DCIS resection may require up to 40 paraffin blocks, and a pathologist needs to examine 100% of the specimen to determine the size and margin status and confirm the absence of occult invasive disease, information crucial to the subsequent treatment decision. This thorough review is time-consuming,
and current reimbursement is not commensurate with the work or materials used. Since the incidence of DCIS is rising, the low reimbursement rate is a major issue.


Oops! This is not important, instead lets talk about transformation and "rounding with clinicians", while other specialities address real issues.


Do you really think radiologists and surgeons give a s*** about how much ( or little ) we are compensated?
 
Do you care how much or little they are compensated?

No. Particularly when reimbursement totally moves to the "one pie" concept/system and we have to fight for our piece of that one pie.
 
What is the 88361 for?

Granted I'm in the military so we only code until it looks passable, but I don't think I've ever coded that/

Computer aided analysis of immunos. Such as quantifying % positive cells on a vias by ventana which is commonly done for breast biopsies
 
No. Particularly when reimbursement totally moves to the "one pie" concept/system and we have to fight for our piece of that one pie.

I don't understand how that system could ever operate. The only way would be to have complete control of the process by a system or large hospital. Distribution of the leavings is by necessity going to become harsh and unfair. Certain types of physicians could hold others (and the hospital) hostage. I mean shoot, that already happens now when certain docs don't want to take call or cover the ERs. It is going to have to be regulated and probably won't end up being much different then it is now, except for the fact that the $$$ amounts will be smaller for everyone. :rolleyes:
 
I don't understand how that system could ever operate. The only way would be to have complete control of the process by a system or large hospital. Distribution of the leavings is by necessity going to become harsh and unfair. Certain types of physicians could hold others (and the hospital) hostage. I mean shoot, that already happens now when certain docs don't want to take call or cover the ERs. It is going to have to be regulated and probably won't end up being much different then it is now, except for the fact that the $$$ amounts will be smaller for everyone. :rolleyes:
you pretty much answer the question when you say " complete control of the process by a large ststem". I am sure you know of DRG's. And incidentially, thru that, most of us don't get our share of the professional component for clinical path for medicare patients from the feds or from insurers which have followed them in lock-step. The gov/insurer says " why, we already include that money as payment which we send to the hospital and you will have to look to them for that share of your portion". Good luck when you approach your local HCA hospital where you have a contract and ask them to please pass thru your share! Anyways, I got off topic.

Have you heard of RAP drg's? That is where there is one pie for a DRG code which will be divided amongst the rads, gas passers and pathologists.
The size of the pie is determned by "complete control of a large system" such as the feds or the Blues and the size of your slice will be determined by a cage fight between the 3 specialities. This concept may be expanded to include all specialties involved. Oh, how do you think our wonderful CAP and "organized pathology" will do in a cage fight with radiology?
 
I don't understand how that system could ever operate. The only way would be to have complete control of the process by a system or large hospital. Distribution of the leavings is by necessity going to become harsh and unfair. Certain types of physicians could hold others (and the hospital) hostage. I mean shoot, that already happens now when certain docs don't want to take call or cover the ERs. It is going to have to be regulated and probably won't end up being much different then it is now, except for the fact that the $$$ amounts will be smaller for everyone. :rolleyes:

Single payments will be the future in a few years. It will be a disaster for pp parhologists especially those working at for profit hospitals like those owned by hca. They are preparing to go public and will need to maximize profits. So how will they will do all they can to screw all docs
 
Single payments will be the future in a few years. It will be a disaster for pp parhologists especially those working at for profit hospitals like those owned by hca. They are preparing to go public and will need to maximize profits. So how will they will do all they can to screw all docs

our organization has a number of hca hospitals and they are going to drop all the contracts and hire their own employee pathologists. I am sure they will be able to pay a very *****rdly salary and have the poor pathologists manning every committee in the hospital. i am so glad i began this s*** in 1977 rather than 2007 and i am more thankful that i convinced my son to be a lawyer.
 
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