Palmetto-gba finalizes ancillary stain coverage
- Thread starter AZpath
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I'm confused.
At a meeting I attended Dr. Stephen Black-Schaffer, Mass Gen pathologist and vice-chair of the CAP Economic Affairs Committee, gave a great rundown of how and why CMS is targeting pathology. But when he got to the Palmetto LCD he made the argument that Jeter is challenging our ability to order IHC/stains at all, and that these ancillary studies would have to be generated by the clinicians. That would obviously be terrible for patients, pathologists, healthcare, the United States of America, koalas... etc.
But looking at pathblawg it seems like Jeter's specifically targeting the obviously abusive practice of pre-ordering stains X, Y, Z on every specimen W. We should all oppose that, right? 'Cause that's wasteful and abusive and makes us all look like crooks. Who's right, Dr. SBS or pathblawg? Is CAP/SBS just trying to get ahead of what they see as the inevitable next argument?
At a meeting I attended Dr. Stephen Black-Schaffer, Mass Gen pathologist and vice-chair of the CAP Economic Affairs Committee, gave a great rundown of how and why CMS is targeting pathology. But when he got to the Palmetto LCD he made the argument that Jeter is challenging our ability to order IHC/stains at all, and that these ancillary studies would have to be generated by the clinicians. That would obviously be terrible for patients, pathologists, healthcare, the United States of America, koalas... etc.
But looking at pathblawg it seems like Jeter's specifically targeting the obviously abusive practice of pre-ordering stains X, Y, Z on every specimen W. We should all oppose that, right? 'Cause that's wasteful and abusive and makes us all look like crooks. Who's right, Dr. SBS or pathblawg? Is CAP/SBS just trying to get ahead of what they see as the inevitable next argument?
I oppose Palmetto's endeavor because it sets the precedent that direct patient care decisions can rest with insurance companies, not physicians. We become not the leaders of patient care but another technical staff member.
I also find it odd that, with all of the rampant, blatant corruption in pathology (abuses of the IOASE by outpatient biopsy mills, residency programs recruiting foreign-trained menaces-to-society to keep within budget etc) that this is the issue Palmetto decides to become sanctimonious on.
I also find it odd that, with all of the rampant, blatant corruption in pathology (abuses of the IOASE by outpatient biopsy mills, residency programs recruiting foreign-trained menaces-to-society to keep within budget etc) that this is the issue Palmetto decides to become sanctimonious on.
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Why is CMS targeting pathology according to SBS?
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In short, the way we make money is very different from other drs.
In long:
-A typical encounter for a dr. generates 1-2 charges. Anatomic path average 6+ charges/case.
-CMS specifically looks for "Multiple codes that are frequently billed in conjunction with furnishing a single service." Because that scenario correlates with waste fraud and abuse.
-In theory, there are efficiencies when a service is furnished at the same time as other services (e.g. The sixth IHC stain you run should require less cost and effort to perform and interpret than the first. Not saying I agree, mind you.)
-88305, our most common code, is difficult to value. The previous vignette used to value the 88305 was a TURP, with an average of two blocks submitted. Now the most common 88305 is (sigh) a skin biopsy. In further evaluating the 88305, however, a huge range of specimens requiring a huge range of time and effort are included. This bothers CMS. CMS doesn't like things it cannot quantify. CMS must destroy the 88305 (maybe).
In long:
-A typical encounter for a dr. generates 1-2 charges. Anatomic path average 6+ charges/case.
-CMS specifically looks for "Multiple codes that are frequently billed in conjunction with furnishing a single service." Because that scenario correlates with waste fraud and abuse.
-In theory, there are efficiencies when a service is furnished at the same time as other services (e.g. The sixth IHC stain you run should require less cost and effort to perform and interpret than the first. Not saying I agree, mind you.)
-88305, our most common code, is difficult to value. The previous vignette used to value the 88305 was a TURP, with an average of two blocks submitted. Now the most common 88305 is (sigh) a skin biopsy. In further evaluating the 88305, however, a huge range of specimens requiring a huge range of time and effort are included. This bothers CMS. CMS doesn't like things it cannot quantify. CMS must destroy the 88305 (maybe).
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There is no legitimate reason to order special stains up front before seeing the case. This type of situation is ripe for abuse and I don't really have any patience for people who insist it's totally justified. Unfortunately, those who abuse the situation make more typical and ethical practice more problematic and difficult. 88305 would not be under nearly as much pressure without the excessive specimen submission from in-office labs. 88342 would not be under as much pressure without excessive ordering like CD3/CD20 on every small bowel biopsy or PIN4 on every prostate core or a panel of stains on every lung cancer. Unfortunately when things like this happen it becomes even harder, paradoxically, to defend legitimate practice. Because whatever they change, the unethical will just alter their practice to take the most advantage possible of the new situation.
There are probably going to be other things like this popping up in other fields - forcing docs to justify when they order tests that don't fit criteria. Like bone scans for every prostate cancer patient, for example. Frequency of screening procedures, etc.
There are probably going to be other things like this popping up in other fields - forcing docs to justify when they order tests that don't fit criteria. Like bone scans for every prostate cancer patient, for example. Frequency of screening procedures, etc.
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Is the breath urease test under fire too? I'm sure that is done at every GI visit. Does every patient need it?
