How do others in the real world bill the following...

[SLUsagar]

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I'm hoping this thread stays on topic with folks OUT IN THE REAL WORLD offering comments on how they bill certain specimens/procedures, so others can learn and compare to their own practices.

Hysterectomy with fibroids -- 88307 (uterus, "not tumor/prolpase") vs 88309 (uterus with "tumor")?

Staging lymph nodes as part of an ovarian serous carcinoma staging: (ovary is 88307), but do you consider the LN's as biopsies (88305) or regional LN resections (88307)?

 

[PresterJohn]

Uterus with leiomyomas are 88307 - I've ran across this several times in CAP publications.

For lymph nodes, we do 88305 if there is only a single node (by gross exam) and 88307 if there appears to be more than one. It's arbitrary, but then again, so is most of cpt coding.

While we're on the topic of gyn cases, I constantly see cases where pathologists don't bundle specimens submitted in separate containers. For example, a non-neoplastic uterus & adnexae in separate containers should be 88307x1, not 88307x1 & 88305x2. I've stopped debating this with colleagues because it just doesn't stick. Anyone else have problems with that?

 

[SLUsagar]

Uterus with leiomyomas are 88307 - I've ran across this several times in CAP publications.

For lymph nodes, we do 88305 if there is only a single node (by gross exam) and 88307 if there appears to be more than one. It's arbitrary, but then again, so is most of cpt coding.

While we're on the topic of gyn cases, I constantly see cases where pathologists don't bundle specimens submitted in separate containers. For example, a non-neoplastic uterus & adnexae in separate containers should be 88307x1, not 88307x1 & 88305x2. I've stopped debating this with colleagues because it just doesn't stick. Anyone else have problems with that?

I completely concur about the 88307 fibroid uterus and LN # issue...if I can get all the regionally resected LN's in 1 cassette, 88305, otherwise 88307.
I think a lot of pathologists don't bundle b/c it's a pain to have to make a executive decision on a per-case basis, sometimes easier to just take them as they come in a standard fashion (i.e. if surgeon make a point to separately submit and label in diff containers, follow suit). Say for example the uterus had a usual endomet ca (88309) but the separately submitted ovarian tumors had (for example) example a yolk sac tumor in 1 and a pap serous ca in the other. Now pretend all 3 specimens are 1 container (and you can differential L from R ovary). In each situation, would you still bundle the 88309 or do 2 add'l (or 1?) 88307.

Another controversial one is derm... bx w/melanoma is a straightforward 88305. Although technically a Hugh Jass skin excision for melanoma falls under the same code, but I know many folks who say they'd go to court to defend billing out an 88307.

 

[mcfaddens]

I completely concur about the 88307 fibroid uterus and LN # issue...if I can get all the regionally resected LN's in 1 cassette, 88305, otherwise 88307.
I think a lot of pathologists don't bundle b/c it's a pain to have to make a executive decision on a per-case basis, sometimes easier to just take them as they come in a standard fashion (i.e. if surgeon make a point to separately submit and label in diff containers, follow suit). Say for example the uterus had a usual endomet ca (88309) but the separately submitted ovarian tumors had (for example) example a yolk sac tumor in 1 and a pap serous ca in the other. Now pretend all 3 specimens are 1 container (and you can differential L from R ovary). In each situation, would you still bundle the 88309 or do 2 add'l (or 1?) 88307.

Another controversial one is derm... bx w/melanoma is a straightforward 88305. But technically, a Hugh Jass skin excision for melanoma falls under the same code, but I know many folks who say they'd go to court to defend billing out an 88307.

I agree Uterus no cancer 88307 (I guess your comped to your PA's work on that one like placentas)
Uterus with cancer 88309 lymph nodes 88305
Fortunately in my experience I have yet to run into multiple gyn tumors submitted as one specimen. I have had a colon with primary tumor and metastatic deposits from another location and just billed an 88309.
For skins here everything including resections are 88305's. I will usually throw in an immuno to make sure I am seeing all of the tumor on melanoma resections (have seen this from derm consultants and review of outside cases) so the immuno falls into local practice standards.

 

[SLUsagar]

I agree Uterus no cancer 88307 (I guess your comped to your PA's work on that one like placentas)
Uterus with cancer 88309 lymph nodes 88305
Fortunately in my experience I have yet to run into multiple gyn tumors submitted as one specimen. I have had a colon with primary tumor and metastatic deposits from another location and just billed an 88309.
For skins here everything including resections are 88305's. I will usually throw in an immuno to make sure I am seeing all of the tumor on melanoma resections (have seen this from derm consultants and review of outside cases) so the immuno falls into local practice standards.

speaking of placentas...don't forgot: twin placentas are 88307 x 2!

 

[caffeinegirl]

Another controversial one is derm... bx w/melanoma is a straightforward 88305. Although technically a Hugh Jass skin excision for melanoma falls under the same code, but I know many folks who say they'd go to court to defend billing out an 88307.

Nice to know that this is controversial..it definitely is over here around these parts. I don't understand how a 20+ block case for a resection is billed the same as a 1 block biopsy....

 

[Whetherby]

Nice to know that this is controversial..it definitely is over here around these parts. I don't understand how a 20+ block case for a resection is billed the same as a 1 block biopsy....

It doesn't make any sense but neither does any of the CPT coding. As it was once explained to me by a senior pathologist, some things are underpaid but others are overpaid, so (as long as you're doing a variety of different types of cases) it all evens out in the end. It's better just to accept it rather than to try to make any sense of it.

 

[malchik]

Agree that much of current CPT coding makes no sense. Ex: Skin shave for seborrheic keratosis: 88305. Bone marrow biopsy: 88305.

If we get regional lymph nodes that have to be dissected from the fat, that is a lymph node dissection = 88307. Single lymph node we code 88305.

 

[SLUsagar]

ok here's another one I'd to see what all everyone is doing...

situation A:
let's say you've got a lung wedge resection with necrotizing granulomas, and you wanna do AFB and GMS on several blocks from the case (say you do AFB and GMS from 2 blocks). In addition to the 88307 for the lung wedge, would you do 88312 (stains for bugs) x 2 or x 4?

situation B:
Essentially addressing a similar topic...let's say you've got a lung wedge with patchy sheets of lymphocytes, pt has a history of mantle cell lymphoma, worried about lung involvement. Say you order Bcl-1 (cyclinD1) on several blocks from the case (say 2 blocks). In addition to the 88307 for the lung wedge, would do 88342 (immuno) x1 or x2?

[yes, I'm sure you'd add other immunos like CD20, PAX5, etc. but just trying to make a point]

 

[Pingu]

speaking of placentas...don't forgot: twin placentas are 88307 x 2!

You can only bill x2 on twin placentas if there are clamps designating baby A/baby B. No clamps or designation on a twin placenta bills as a 88307 x1.🙁

 

[deleted314957]

ok here's another one I'd to see what all everyone is doing...

situation A:
let's say you've got a lung wedge resection with necrotizing granulomas, and you wanna do AFB and GMS on several blocks from the case (say you do AFB and GMS from 2 blocks). In addition to the 88307 for the lung wedge, would you do 88312 (stains for bugs) x 2 or x 4?

situation B:
Essentially addressing a similar topic...let's say you've got a lung wedge with patchy sheets of lymphocytes, pt has a history of mantle cell lymphoma, worried about lung involvement. Say you order Bcl-1 (cyclinD1) on several blocks from the case (say 2 blocks). In addition to the 88307 for the lung wedge, would do 88342 (immuno) x1 or x2?

[yes, I'm sure you'd add other immunos like CD20, PAX5, etc. but just trying to make a point]

the lesser of the codes. it is special stains pre case, not per block. if you did a gms on each of 10 blocks in a lung case it would only be 88312x1

 

[SLUsagar]

You can only bill x2 on twin placentas if there are clamps designating baby A/baby B. No clamps or designation on a twin placenta bills as a 88307 x1.🙁

yes, correct. as long as you can differential specimens sent together you can bill separately, even for minuscule cases like gross-only tonsils (with safety pin in 1 indicating laterality)...88300 x2.

 

[pathstudent]

yes, correct. as long as you can differential specimens sent together you can bill separately, even for minuscule cases like gross-only tonsils (with safety pin in 1 indicating laterality)...88300 x2.

I once reviewed a prostate biopsy where they did two biopsies from 12 sites and inked one black and the other uninked and the urologists billed for 24 88305s at least that was noted on the report in small print "88305 x 24". Just think they are billing the global and maybe paying the pathologist 100 dollars for doing the case while they collect 2400 or at least attempt to. That is probably more than they get for doing the biopsy.

 

[GeoLeoX]

Agree that much of current CPT coding makes no sense. Ex: Skin shave for seborrheic keratosis: 88305. Bone marrow biopsy: 88305.

with a marrow, however, you can charge for decal, Fe, etc. not much but it does add up.

 

[sohsie]

the lesser of the codes. it is special stains pre case, not per block. if you did a gms on each of 10 blocks in a lung case it would only be 88312x1

That actually has recently changed.
http://www.vachettepathology.com/in...-2010&catid=28:associated-knowledge&Itemid=45

 

[SLUsagar]

That actually has recently changed.
http://www.vachettepathology.com/in...-2010&catid=28:associated-knowledge&Itemid=45

THANK YOU for sending this. Wow, so I've actually been billing correctly all along.

 

[green mantis]

This information has been quite helpful. It's infinitely more useful than all those threads about the horrible job market.

How do you handle charges for decalcification? Can you charge an 88311 for each block that requires decal?

I'm not sure if someone can confirm this. An attending of mine always asked us to do a thorough search for hilar lymph nodes in nephrectomy specimens. If we found more than 1, you can bill an additional lymph node dissection. Is this another scenario where you can use multiple 8830X codes for 1 specimen?


----- Antony

 

[pathstudent]

This information has been quite helpful. It's infinitely more useful than all those threads about the horrible job market.

How do you handle charges for decalcification? Can you charge an 88311 for each block that requires decal?

I'm not sure if someone can confirm this. An attending of mine always asked us to do a thorough search for hilar lymph nodes in nephrectomy specimens. If we found more than 1, you can bill an additional lymph node dissection. Is this another scenario where you can use multiple 8830X codes for 1 specimen?


----- Antony

That seems unethical to me. You should report that attending to the cms. A lymph node dissection is part of many specimens and you can't separate that out. Where are you and who is this attending. I want to report them. If the surgeon sent a lymph mode dissection separetely then it is ok to bill for it. Your attending sounds incredibly unethical. It is aholes like him that will ruin the system for everyone just like those urology aholes. Your attendi g is a real creep. What's his name.

 

[moonraker]

That seems unethical to me. You should report that attending to the cms. A lymph node dissection is part of many specimens and you can't separate that out. Where are you and who is this attending. I want to report them. If the surgeon sent a lymph mode dissection separetely then it is ok to bill for it. Your attending sounds incredibly unethical. It is aholes like him that will ruin the system for everyone just like those urology aholes. Your attendi g is a real creep. What's his name.

You are a giant douche. I'm sure we are all curious as to who YOU are too. You're probably in one of those Boston programs, aren't you? Maybe Brigham since all you do is talk about how great Brigham is. Or UCSF since you can't shut up about them too? Or maybe you're in a crappy program and you're some kind of wannabe.

 

[BU Pathology]

The College of American Pathologists has a number of articles about CPT billing. Several of these are available for free on the website and are printed in their publication, CAP Today.
http://www.cap.org/apps/cap.portal?...g/cpt.html&_state=maximized&_pageLabel=cntvwr

This also answers the question what has CAP done for me, they provide suggestions about how to properly bill.

Note: I am not a member of CAP although I do read their publications.

 

[SLUsagar]

This information has been quite helpful. It's infinitely more useful than all those threads about the horrible job market.

How do you handle charges for decalcification? Can you charge an 88311 for each block that requires decal?

I'm not sure if someone can confirm this. An attending of mine always asked us to do a thorough search for hilar lymph nodes in nephrectomy specimens. If we found more than 1, you can bill an additional lymph node dissection. Is this another scenario where you can use multiple 8830X codes for 1 specimen?
----- Antony

Tony,
I'm gonna avoid such childish comments that followed your initial post and instead commend you on contributing to this thread.

decal: ok initially I was and have been billing just 1 decal for the entire case (i.e. L/R sinonasal contents needing decal gets 88304x2, 88311x1) but I should note that the recent updated CPT billing that someone posted on a hyperlink talked about how technically as long as you comment on it, you can separate bugs/special stains and IHC on multiple blocks within the same case. Only kicker is that of the codes listed I didn't see the decal code, so perhaps we can't.

LNs: I don't think you can bill a separate LN dissection in the example you gave. Similarly, colon resections for tumor are 88309x1 (plus the medicare 3260F code), but no separate 88307 for LN dissection, I'd include it as part of the specimen, even for ones that you wouldn't normally search for nodes in as extensively.

Just my $0.02

 

[SLUsagar]

That actually has recently changed.
http://www.vachettepathology.com/in...-2010&catid=28:associated-knowledge&Itemid=45

Can someone please post/copy where exactly this is cited in the updated 2010 CPT billing? While I concur with the article, my colleagues just wanna see it in print so we can start applying the new criteria.
thanks

 

[pathdawg]

Pertaining to the OP, here is what doesn't make sense. The CPT is a procedure code, not a diagnosis code. The procedure (hysterectomy for neoplasm) should not be diagnosis-dependent. For example, currently, if you receive a hysterectomy with benign leiomyomas, we all call that an 88307. However, if you find atypia, necrosis, and several mitoses in one of those fibroids and diagnose it as a leiomyosarcoma, then most here would bump it up to an 88309. But either way, its the same procedure. It should therefore be the same code. To me, a leiomyoma is a neoplastic process. It should therefore be 88309. I count mitoses in at least 10 HPF's whether its benign or not. Same pathology procedure regradless of the actual diagnosis.

 

[2121115]

Aren't there several examples of cases where the excision procedure is the same but the CPT code changes with the diagnosis. I'm thinking particularly of derm cases (irritated SK, skin tag). Also inflammatory nasal polyps vs other. These are just off the top of my head, not sure if they are accurate.

 

[lipomas]

I have always thought you could bill decals per specimen. Thus, if you have bilateral knee replacements for example, that is 88311 x 2. It is similar to special stains.

The above about billing twice for stains done on two blocks of the SAME specimen (like slides 1A and 1B) is new to me.

I do not believe you can bill for a lymph node dissection in a surgical resection case like a kidney or colon or breast. You are theoretically allowed to bill for multiple separately identified specimens within one specimen. That is, if you get a distal pancreas + spleen and the surgeon writes, "Spleen + Pancreas, stitch on pancreas, history of tumor in pancreas with splenic nodule" you could bill for both instead of just the pancreas.

In regards to 2121115's post, I believe that is true. It's like for lipomas. If you do an excision of a soft tissue lump, if it comes out to be a cyst or a lipoma it has to be 88304, but if it turns out to be a schwannoma it's an 88305. Unfortunately this means that when you get 8 blocks on an "axillary mass" that turns out to be a lipoma, it's just an 88304 x 1.

 

[pathstudent]

I have always thought you could bill decals per specimen. Thus, if you have bilateral knee replacements for example, that is 88311 x 2. It is similar to special stains.

The above about billing twice for stains done on two blocks of the SAME specimen (like slides 1A and 1B) is new to me.

I do not believe you can bill for a lymph node dissection in a surgical resection case like a kidney or colon or breast. You are theoretically allowed to bill for multiple separately identified specimens within one specimen. That is, if you get a distal pancreas + spleen and the surgeon writes, "Spleen + Pancreas, stitch on pancreas, history of tumor in pancreas with splenic nodule" you could bill for both instead of just the pancreas.

In regards to 2121115's post, I believe that is true. It's like for lipomas. If you do an excision of a soft tissue lump, if it comes out to be a cyst or a lipoma it has to be 88304, but if it turns out to be a schwannoma it's an 88305. Unfortunately this means that when you get 8 blocks on an "axillary mass" that turns out to be a lipoma, it's just an 88304 x 1.

Seriously. Anyone who adds an 88307 to a colectomy for carcinoma (88309) or to a kidney case (88307) is a mother F'n scammer. It is part of the specimen and unless it is sent separately, you can't bill extra for it. It is how the game is set up and you gotta play by the rules. Sometimes the rules help you out, other times they don't. Say if on a Whipple, they send the bile duct, pancreatic margin, distal and proximal margins separately, then you get bill an 88331x4, 88305x4, and 88309. If they just send you the whipple and ask for margins on frozen, then you just get to bill an 88331x1, 88332x3, and an 88309. Yeah it sucks, but you got to play by the rules, or you risk turning over the turnip cart with the bathwater. that's why that guy's attending who tacks on an 88307 if his resident finds lymph nodes on a nephrectomy really pisses me off. He is a scammer and should be reported to his state medical board and the cms. dude ain't playing by the rules. tell me his name now!!!!

 

[pathstudent]

You are a giant douche. I'm sure we are all curious as to who YOU are too. You're probably in one of those Boston programs, aren't you? Maybe Brigham since all you do is talk about how great Brigham is. Or UCSF since you can't shut up about them too? Or maybe you're in a crappy program and you're some kind of wannabe.

yeah sure I am a giant douche but at least I don't bend the rules and won't f'n f up pathology reimbursements for little douches like you. And what sort of immature jerk-off uses the word douche? Only a douche like you.

 

[pathstudent]

Pertaining to the OP, here is what doesn't make sense. The CPT is a procedure code, not a diagnosis code. The procedure (hysterectomy for neoplasm) should not be diagnosis-dependent. For example, currently, if you receive a hysterectomy with benign leiomyomas, we all call that an 88307. However, if you find atypia, necrosis, and several mitoses in one of those fibroids and diagnose it as a leiomyosarcoma, then most here would bump it up to an 88309. But either way, its the same procedure. It should therefore be the same code. To me, a leiomyoma is a neoplastic process. It should therefore be 88309. I count mitoses in at least 10 HPF's whether its benign or not. Same pathology procedure regradless of the actual diagnosis.

No but CMS specifies that uteruses for leiomyomas are the same as non-neoplastic urteruses and are 88307s. You are being a douche for billing it as a neoplasm. The CMS specifically specifies that it is an 88307 just like it specifies that uteruses for prolapse are 88305s.

 

[subbacultcha]

Went to a conference recently that went through a lot of these issues. Speaker confirmed that, yes, you can now bill per IHC per BLOCK.

One frightening concept - say your part A is the mastectomy and part B is the ipsilateral axillary nodes. I learned in residency that you bill for the mastectomy and part B gets its own 88305. Recent speaker said they are, in fact, bundled, and you can only charge for the mast.

I left the handouts at work but some of the stuff was frightening.

 

[green mantis]

Here's another couple scenarios for all of you. If a specimen comes w/ hardware, can you bill a separate gross only (88300)? What about the opposite situation? I'm sure some of you get IUDs that you scrape for Actinomyces.


----- Antony

 

[pathdawg]

No but CMS specifies that uteruses for leiomyomas are the same as non-neoplastic urteruses and are 88307s. You are being a douche for billing it as a neoplasm. The CMS specifically specifies that it is an 88307 just like it specifies that uteruses for prolapse are 88305s.

First, I do not bill a fibroid uterus hysterectomy as a Level VI (88309). My point is, why do we all accept that a fibroid uterus is a level V (88307) when CMS states that a uterus with neoplasm is a level VI? A leiomyoma is a neoplasm, no? A pathologist performs the same procedure for diagnosing a leiomyoma as he would a leiomyosarcoma. Why should he accept less payment simply because the neoplam happens to be benign?

No other profession would take this inconsistent and unfair payment practice laying down. None. Only physicians are so clueless as to not only accept this, but berate one of their own for actually questioning this unfair practice.

I have seen the douche, and it is us.

 

[Path or bust]

First, I do not bill a fibroid uterus hysterectomy as a Level VI (88309). My point is, why do we all accept that a fibroid uterus is a level V (88307) when CMS states that a uterus with neoplasm is a level VI? A leiomyoma is a neoplasm, no? A pathologist performs the same procedure for diagnosing a leiomyoma as he would a leiomyosarcoma. Why should he accept less payment simply because the neoplam happens to be benign?

No other profession would take this inconsistent and unfair payment practice laying down. None. Only physicians are so clueless as to not only accept this, but berate one of their own for actually questioning this unfair practice.

I have seen the douche, and it is us.

Well, I think there really is no great consensus on this, as you mentioned. People are not readily wanting to commit fraud or be accused of defrauding CMS, so you play it safe with an 88307.

 

[pathstudent]

First, I do not bill a fibroid uterus hysterectomy as a Level VI (88309). My point is, why do we all accept that a fibroid uterus is a level V (88307) when CMS states that a uterus with neoplasm is a level VI? A leiomyoma is a neoplasm, no? A pathologist performs the same procedure for diagnosing a leiomyoma as he would a leiomyosarcoma. Why should he accept less payment simply because the neoplam happens to be benign?

No other profession would take this inconsistent and unfair payment practice laying down. None. Only physicians are so clueless as to not only accept this, but berate one of their own for actually questioning this unfair practice.

I have seen the douche, and it is us.

I can't speak for the CMS but I imagine that they view leiomyomas as incredibly common benign neoplasm which causes women to get the uteri out. You bivalve a Ute with a 2 cm leiomyoma and I don't think that is as nearly as involved to gross/micro as one with a malignancy.

What I don't get is that an appendix for incidental is an 88302 and for "any other reason it is an 88304." Even if it has a carcionid, adenocarcinoma, or lymphoma or Chron's, you still have to bill it as an 88304. That doesn't make sense to me. Samething with Gallbladders that have a cancer, you still have to bill them an 88304, unless you are willing to commit fraud. A lymph node for lymphoma is the same as tubular adenoma (88305). That seems weird to me as lymphomas can involved nearly an hour of study while a GI bx of a TA takes ten seconds to look at and dictate.

But on the bright side placentas are 88307.

 

[Whetherby]

I can't speak for the CMS but I imagine that they view leiomyomas as incredibly common benign neoplasm which causes women to get the uteri out. You bivalve a Ute with a 2 cm leiomyoma and I don't think that is as nearly as involved to gross/micro as one with a malignancy.

What I don't get is that an appendix for incidental is an 88302 and for "any other reason it is an 88304." Even if it has a carcionid, adenocarcinoma, or lymphoma or Chron's, you still have to bill it as an 88304. That doesn't make sense to me. Samething with Gallbladders that have a cancer, you still have to bill them an 88304, unless you are willing to commit fraud. A lymph node for lymphoma is the same as tubular adenoma (88305). That seems weird to me as lymphomas can involved nearly an hour of study while a GI bx of a TA takes ten seconds to look at and dictate.

But on the bright side placentas are 88307.

I've said it before but I'll say it again: There is absolutely no point in trying to make logical sense of the CPT coding system. It will only cause frustration.

Should we be paid more for a gallbladder with cancer? Probably. Do we really deserve an 88305 for an SK? Probably not. But it all evens out in the end, so just be happy that the bills are as high as they are. And yes, despite what some people believe, pathology cases are compensated very well (although how much each of us actually gets of that bill is another matter...).

 

[pathdawg]

despite what some people believe, pathology cases are compensated very well.

I could not possibly disagree more.

The fear-based rhetoric (i.e. if we dare bill more for the work we are rightfully doing, we'll be committing fraud) and the naiive acceptance of our reimbursement rates (i.e. despite it all, we are actually reimbursed very well) is not serving our profession well al all.

 

[deleted314957]

I could not possibly disagree more.

The fear-based rhetoric (i.e. if we dare bill more for the work we are rightfully doing, we'll be committing fraud) and the naiive acceptance of our reimbursement rates (i.e. despite it all, we are actually reimbursed very well) is not serving our profession well al all.

That may be a noble and justifiable attitude but it vaporizes immediately when your new pathology publicly-owned company tanks from $12 to $3.50 the day after there is an (eventually unsubstantiated) investigation announced by CMS about fradulent billing and you hold 10's of thousands of shares. (and because I knew CMS was full of s*** I bought, but you sweat your balls off!)

 

[Whetherby]

I could not possibly disagree more.

The fear-based rhetoric (i.e. if we dare bill more for the work we are rightfully doing, we'll be committing fraud) and the naiive acceptance of our reimbursement rates (i.e. despite it all, we are actually reimbursed very well) is not serving our profession well al all.

Whatever dude. At the good end of the spectrum, an easy 88305 case (SK, tubular adenoma, etc.) takes about 10 seconds to diagnose and is compensated about $100. At the bad end of the spectrum, a long 88309 case takes maybe 30-40 minutes and is compensated about $300-350...still pretty good. Do you know how much time an internist, neurologist, psychiatrist, etc. spends on a difficult case and how much they are compensated for it?

The big problem is not how much we can bill per case but how much of it we actually see. Work out the numbers - any practicing pathologist with a reasonable workload will bill at least 500k-1M per year, usually more. The only reason that most pathologists make less than that is because someone else is keep most of that money - the employer, the academic institution, the clinicians who are getting kickbacks, the shareholders of the corporate lab, etc.

If you really want to improve pathologists salaries, work on fixing these screwed up situations, not the billing.

 

[deleted314957]

Whatever dude. At the good end of the spectrum, an easy 88305 case (SK, tubular adenoma, etc.) takes about 10 seconds to diagnose and is compensated about $100. At the bad end of the spectrum, a long 88309 case takes maybe 30-40 minutes and is compensated about $300-350...still pretty good. Do you know how much time an internist, neurologist, psychiatrist, etc. spends on a difficult case and how much they are compensated for it?

The big problem is not how much we can bill per case but how much of it we actually see. Work out the numbers - any practicing pathologist with a reasonable workload will bill at least 500k-1M per year, usually more. The only reason that most pathologists make less than that is because someone else is keep most of that money - the employer, the academic institution, the clinicians who are getting kickbacks, the shareholders of the corporate lab, etc.

If you really want to improve pathologists salaries, work on fixing these screwed up situations, not the billing.

Sure your employer is going to make money on you but remember, when I was an owner along with my 12 other partners we billed out about 36 million a year. we did not make $2.77 million salary a year each. we made $500-$700. There were such things as salaries, benefits etc for about a dozen associates, salaries/benefits for about 100 other employees, rent, insurance, legal fees etc.,etc. you get the idea.

 

[rollwithit]

The big problem is not how much we can bill per case but how much of it we actually see. Work out the numbers - any practicing pathologist with a reasonable workload will bill at least 500k-1M per year, usually more. The only reason that most pathologists make less than that is because someone else is keep most of that money - the employer, the academic institution, the clinicians who are getting kickbacks, the shareholders of the corporate lab, etc.

If you really want to improve pathologists salaries, work on fixing these screwed up situations, not the billing.

That's not a screwed up situation. That's reality. Do you think a staff accountant at a public accounting firm billing 1,800 hours out at $150/hr sees anything close to $270k a year? Heeeccckkk no. There's a ton of overhead that $270k is designed to cover. Plus, owners of a firm SHOULD be rewarded for bearing the risk of starting up business or being an owner.

This is going to happen in any business, why should Pathology be any different? You aren't ever going to "fix these situations". If the discrepancy between the revenues you generate and what you see from it bothers you, start your own practice or figure out a way get free equipment and a support staff that will work for free.

Maybe a business class or two should be included in med school??

 

[Whetherby]

That's not a screwed up situation. That's reality. Do you think a staff accountant at a public accounting firm billing 1,800 hours out at $150/hr sees anything close to $270k a year? Heeeccckkk no. There's a ton of overhead that $270k is designed to cover. Plus, owners of a firm SHOULD be rewarded for bearing the risk of starting up business or being an owner.

This is going to happen in any business, why should Pathology be any different? You aren't ever going to "fix these situations". If the discrepancy between the revenues you generate and what you see from it bothers you, start your own practice or figure out a way get free equipment and a support staff that will work for free.

Maybe a business class or two should be included in med school??

Thanks for the suggestion. I'll look into the business school idea.

Obviously there's overhead, I'm not ******ed. That's a fixed cost that you can't do anything about. The screwed up situation I'm talking about has nothing to do with the overhead issue. Here's an example of a screwed up situation:

-Pathologist processes biopsy tissue, reads slide and makes diagnosis
-Pathologist bills clinician $25 for the 'service.' Part of this will be used to cover overhead - as you have so aptly pointed out - and pathologist gets to keep the remainder.
-Clinician bills the patient's insurance directly, receives ~$100 or so, and profits ~$75 for doing nothing and assuming no liability for the diagnosis, plus he bills for the biopsy procedure.

This is a screwed up situation. This is what needs to be fixed. Insurance companies aren't going to start paying $200 for an 88305 instead of $100, so arguing for higher billing isn't going to help anything.

 

[Whetherby]

Sure your employer is going to make money on you but remember, when I was an owner along with my 12 other partners we billed out about 36 million a year. we did not make $2.77 million salary a year each. we made $500-$700. There were such things as salaries, benefits etc for about a dozen associates, salaries/benefits for about 100 other employees, rent, insurance, legal fees etc.,etc. you get the idea.

Do you mean you and the other partners alone billed 36 million per year or that the partners + the associates billed 36 million a year? And do you mean that's the amount that was billed or that's the amount that was received? Where I am, the amount received is maybe 1/3 to 1/2 of the bill.

I have no problem with partners making money off of the employed pathologists, which is commonplace in any field of medicine, law, etc. I have a big problem with clinicians taking a larger chunk of the pathology bill than we do, which as far as I am aware is unique to pathology.

 

[lipomas]

I have no problem with partners making money off of the employed pathologists, which is commonplace in any field of medicine, law, etc. I have a big problem with clinicians taking a larger chunk of the pathology bill than we do, which as far as I am aware is unique to pathology.

It's not unique to pathology - well at least making money off of other clinicians is not unique to pathology. Radiologists have this happen to them when clinicians own their own equipment. I have no doubt that anesthesiologists have this happen to them when they contract with physicians, and not hospitals, for outpatient surgeries. There are also odd quirks in billing where if someone performs a procedure at a hospital the hospital will receive more money than if the procedure was performed elsewhere.

I am unaware of any other field of medicine being able to successfully bill for the professional component of someone else's work, however!

What I really want to do is ask a gastroenterologist how they would feel if I, when signing out a colon biopsy, also requested a cut of the revenue from performing the procedure. I suspect they would get indignant, confused, and refuse. Yet they do this to pathologists and consider it perfectly ethical.

 

[Whetherby]

It's not unique to pathology - well at least making money off of other clinicians is not unique to pathology. Radiologists have this happen to them when clinicians own their own equipment.

I actually don't have a problem with that particular situation, whether in radiology or pathology. Obviously I'd prefer to make the technical component myself, but I don't necessarily think pathologists have have God-given right to be the only ones who can own and run a histo lab. I didn't get any serious training on the technical side of histology in my residency, so I can't claim to have any more of a right to run a histo lab than any other doctor. So if a clinical group wants to start up a lab, put in the capital, and spend the time running it, I can't argue that they don't have a right to do it. Same goes for radiology as far as I'm concerned. I guess the self-referral thing could be an issue, but no one seems to take that very seriously.

However, there are many clinicians taking a major chunk of the global pathology bill without owning the lab, which is probably far more common than clinical groups running their own lab. This is where the problem lies.

I wonder if radiologists do the doctor-billing thing? Does anyone know?

 

[deleted314957]

Do you mean you and the other partners alone billed 36 million per year or that the partners + the associates billed 36 million a year? And do you mean that's the amount that was billed or that's the amount that was received? Where I am, the amount received is maybe 1/3 to 1/2 of the bill.

I have no problem with partners making money off of the employed pathologists, which is commonplace in any field of medicine, law, etc. I have a big problem with clinicians taking a larger chunk of the pathology bill than we do, which as far as I am aware is unique to pathology.

Of course it included the associates and the figure was billings, not collections (I wished). After all salaries /bills/overhead was paid there would be about 6 million or so left over which was bonused out to all partners, associates and employees.

 

[Whetherby]

Of course it included the associates and the figure was billings, not collections (I wished). After all salaries /bills/overhead was paid there would be about 6 million or so left over which was bonused out to all partners, associates and employees.

OK, that makes more sense. Total billing amounts seem kind of meaningless to me since collections are never anywhere close to that.

 

[Euchromatin]

I just want to thank everyone who has contributed to this thread. As a graduating medical student preparing to start a pathology residency this summer, I have found it to be very educational. It has given me at least a rough foundation of knowledge about commonly used CPT codes, some of the situations in which discrepancy between institutions exists, and a taste of the complexity of insurance billing and practice management. I know this is only the tip of the iceberg and I hope to learn a lot more in this vein during my residency training, but now I feel a little less clueless. Thanks!

 

[rollwithit]

Thanks for the suggestion. I'll look into the business school idea.

Obviously there's overhead, I'm not ******ed. That's a fixed cost that you can't do anything about. The screwed up situation I'm talking about has nothing to do with the overhead issue. Here's an example of a screwed up situation:

-Pathologist processes biopsy tissue, reads slide and makes diagnosis
-Pathologist bills clinician $25 for the 'service.' Part of this will be used to cover overhead - as you have so aptly pointed out - and pathologist gets to keep the remainder.
-Clinician bills the patient's insurance directly, receives ~$100 or so, and profits ~$75 for doing nothing and assuming no liability for the diagnosis, plus he bills for the biopsy procedure.

This is a screwed up situation. This is what needs to be fixed. Insurance companies aren't going to start paying $200 for an 88305 instead of $100, so arguing for higher billing isn't going to help anything.

I apologize. I assumed you were speaking broadly.

Yes, that's a problem that needs fixing. That's unethical behavior, at best. In that situation, the Pathologist is no doubt getting screwed over. The clinicians that create that environment and the pathologists that caved in and let it happen need to be taken out back and beaten.

 

[deleted314957]

I just want to thank everyone who has contributed to this thread. As a graduating medical student preparing to start a pathology residency this summer, I have found it to be very educational. It has given me at least a rough foundation of knowledge about commonly used CPT codes, some of the situations in which discrepancy between institutions exists, and a taste of the complexity of insurance billing and practice management. I know this is only the tip of the iceberg and I hope to learn a lot more in this vein during my residency training, but now I feel a little less clueless. Thanks!

I have come to (almost) believe that the correct answer to the old question;"is medicine an art or a science?" is ---"Neither; it is a business".
Best of wishes in your future endevours.

 

[SLUsagar]

At the good end of the spectrum, an easy 88305 case (SK, tubular adenoma, etc.) takes about 10 seconds to diagnose and is compensated about $100.

Do you mean $100 for PC+TC? I ask b/c most folks billing out typically get FAR less than that, usually depending on which insurance co.

ex: for an 88305 from a large-size private insurance co, we are all over the place in terms of compensation for the PC component, ranging from $28 to $90 (I'd guess the median is $55). For Medicare, we get $41. Getting $100 back on the $150 we bill out for PC is pretty uncommon.

What all do others bill out for PC? (and how much do you typcially get back, from large insurances and Medicare?)

 

[Whetherby]

Do you mean $100 for PC+TC? I ask b/c most folks billing out typically get FAR less than that, usually depending on which insurance co.

ex: for an 88305 from a large-size private insurance co, we are all over the place in terms of compensation for the PC component, ranging from $28 to $90 (I'd guess the median is $55). For Medicare, we get $41. Getting $100 back on the $150 we bill out for PC is pretty uncommon.

What all do others bill out for PC? (and how much do you typcially get back, from large insurances and Medicare?)

I meant $100 for the entire PC+TC, which is about the average for a medicare reimbursement for an 88305. It varies by location...I think from about $85 to $120.

There's a website where you can look up exactly what medicare pays for each CPT anywhere in the country: https://catalog.ama-assn.org/Catalog/cpt/cpt_search.jsp The amounts given there are for PC+TC, and I don't think it gives you the breakdown of the two components. But I think the average for PC alone is around $40-45, and for TC is around $55-60.

My experience with reimbursement from insurance companies is highly variable too. I've seen a few examples where they've paid the entire billed charge for an 88305 (I think around $190-200 here, for the entire PC+TC), but in most cases I believe it's just slightly higher than what medicare pays.