IHC billing

[doctor313]

Trying to wrap my head around billing stuff. Is there a maximum number of IHC stains that can be billed for a given specimen (I heard a rumor that there is... but can't find proof for that claim)?

Does it vary by the type of patient insurance? I found this document which suggests that 12 stains is the magic number that can be routinely approved by insurance companies, and any in excess of that would be flagged for review, but it seems like there is no clear-cut rules from what I can tell.

https://www.evicore.com/-/media/files/evicore/clinical-guidelines/solution/lab-management/healthplan/immunohistochemistry-ihc.pdf

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[octopusprime]

There is a max, I think it depends on insurance carrier (don't recall what CMS is, 12 sounds right if not high), would be good for you to find out--when things get flagged (excess IHC, erroneous -42 vs -41 billing, multiple identical IHCs on the same specimen) it holds up payment, sometimes for inordinate lengths of time, sometimes for good, and your billing company might not catch it.

 

[LADoc00]

MEUs.

this is why only NGS can save pathology and why you must have NGS and bill for it to survive.

 

[Spikebd]

MEUs.

this is why only NGS can save pathology and why you must have NGS and bill for it to survive.

What’s an MEU?
I remember surgeons telling me that they get less of the cpt percentage as the codes add up. They said it was important to always bill the highest charge as the first one.

 

[LADoc00]

MUE. medically UNLIKELY edits, my bad. government short hand for "youre screwed because we say so"

 

[cmz]

I've seen billing companies non-compliantly only bill for a certain amount of IHC because they know a certain payer only pays for X number of stains. That will get you in a whole lot of hot water.

To get around the MUE crap, you will have to appeal and provide documentation to support why you did what you did. Whether you get paid for the perceived excess is up to the payer.

 

[deleted314957]

If it has gotten this bad I can suggest a possible work around. Now, one should always comment on each immuno separately in the report. But, if it is necessary to do more than whatever they now allow, tell the clinician he/she will have to write an order in the chart for any further necessary immunos. If they bitch, tell them that is the only way they will get a dx.

 

[cmz]

I always write out my micros and incorporate the IHCs used. The heme-path in me will sometimes make lists and report findings for each and every stain. I also include disclaimers like, "These immunohistochemical stains are deemed medically necessary. Some of the antigens may also be evaluated by flow cytometry. Concurrent evaluation by immunohistochemistry on the <INSERT SPECIMEN TYPE> is indicated in this case in order to correlate immunophenotype with cell morphology and determine extent of involvement, spatial pattern, and focality of potential disease distribution." This allows me to get around the CMS issue where you can't bill for IHC and flow at the same time. The system is royally messed up. When I say this, I mean it is VERY RIPE for abuse.