Thanks a lot urologists

[pathstudent]

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So Medicare has announced a new code that will effectively cap prostate biopsy at the equivalent of 5-6 88305s no matter how many biopsies are done. They were submitting these so called cluster biopsies with up to 60 per case.

Of course medicare was going to put a stop to it but thanks for messing up reimbursement for everyone urology. Thanks to your greed and abusive unethical practices

 

[mlw03]

So Medicare has announced a new code that will effectively cap prostate biopsy at the equivalent of 5-6 88305s no matter how many biopsies are done. They were submitting these so called cluster biopsies with up to 60 per case.

Of course medicare was going to put a stop to it but thanks for messing up reimbursement for everyone.

How is this a bad thing? Won't it prevent waste?

 

[KeratinPearls]

So this is 5-6 88305s for every case not matter if it is GI or dermpath? Do you have a link to this? 60 biopsies per case? I have never heard of this? Bladder biopsies?

 

[pathstudent]

So this is 5-6 88305s for every case not matter if it is GI or dermpath? Do you have a link to this? 60 biopsies per case? I have never heard of this? Bladder biopsies?

Thankfully only prostate

 

[pathstudent]

How is this a bad thing? Won't it prevent waste?

It is definitely bad for urologists, which therefore is good for the rest of humanity.

However, for the few pathology groups that still get prostate biopsies sent to them, it is a bad thing as they are being punished for the abuse of urologists.

Also turncoat pathologists who go do the in office work for these groups will also have their payment from the urologists slashed.

 

[deleted314957]

so this is 5-6 88305s for every case not matter if it is gi or dermpath? Do you have a link to this? 60 biopsies per case? I have never heard of this? Bladder biopsies?

they are called prostate saturation biopsies and even private carriers have requirements before they will be paid for the procedure. Something like 2 prior neg or asap biopsies with rising psa, etc.

 

[pathstudent]

Here are the details for those interested

Medicare Provides Clarification on Coding
of Prostate Biopsies

There has been some ambiguity regarding the Medicare policy for billing and reimbursement of prostate biopsy specimens since the January 1, 2012 version of the National Correct Coding Initiative (NCCI) manual was released. The NCCI manual included ambiguous language which many understood to be another attempt by Medicare to distinguish between the appropriate use of the HCPCS G0416-G0419 codes introduced in 2009 for prostate biopsy specimens collected via the transperineal or "saturation" biopsy technique (PSB) and the use of CPT 88305 for reporting prostate needle biopsies collected via the traditional transrectal ultrasound (TRUS) technique. However, a policy update published by Palmetto GBA last week has shed new light on the curious NCCI language, making it clear that it is Medicare's intent to require the use of these new G-codes for all prostate procedures anytime 5 or more separate specimen are billed. This new policy effectively caps reimbursement for all prostate biopsy specimens, irrespective of the manner in which they were collected.

Impact:

Unfortunately, this change does have a significant financial impact as well. The Medicare Physician Fee Schedule National Payment Amount (unadjusted for locality) for G0416 is $670.88, which represents the equivalent of 6.34 units of 88305 (which has a National Payment Amount of $105.86 per unit). Unfortunately, for those who perform PC-only services, the news is worse still.The National Payment Amount for G0416-26 is $182.10, which represents the equivalent of only 5.0 units of 88305-26, which has a National Payment Amount of $36.08 per unit. Therefore, laboratories and physician practices that typically bill for more than 6 specimens for a prostate biopsy case will see their reimbursement for these cases capped at the equivalent of 6.34 units for a global service and 5.0 units for a PC-only service. For a laboratory or pathology practice that has typically billed for 12 specimens for the average prostate case, the Medicare reimbursement will effectively be reduced by 47% on global cases and by 58% for PC-only cases.

History:
As alluded to above, a new set of HCPCS codes (Healthcare Common Procedure Coding System) were introduced by CMS in 2009. HCPCS codes are procedure codes assigned by Medicare and they are used to identify services not listed in the CPT code book. The codes are primarily utilized by the Medicare program, but private payors may also recognize the codes. Instruction from Medicare indicated these codes should be reported when prostate biopsy specimens were collected via prostate saturation biopsy (PSB) technique. PSB procedures are usually performed from a transperineal approach under general anesthesia, using ultrasound technology. This allows the urologist to label each core as to site and creates a map of the precise location of each biopsy. Since this technique results in large numbers of biopsies (typically 30-40"), Medicare wanted to update the established payment policy of reimbursing one unit of 88305 for each separately identifiable core. Therefore, the following HCPCS codes were established for reporting prostate saturation biopsies:
• G0416- Surgical pathology, gross and microscopic examination for prostate needle saturation biopsy sampling, 1-20 specimens
• G0417- Surgical pathology, gross and microscopic examination for prostate needle saturation biopsy sampling, 21-40 specimens
• G0418- Surgical pathology, gross and microscopic examination for prostate needle saturation biopsy sampling, 41-60 specimens
• G0419- Surgical pathology, gross and microscopic examination for prostate needle saturation biopsy sampling, greater than 60 specimens

 

[LNsquasher]

Here are the details for those interested

Medicare Provides Clarification on Coding
of Prostate Biopsies

There has been some ambiguity regarding the Medicare policy for billing and reimbursement of prostate biopsy specimens since the January 1, 2012 version of the National Correct Coding Initiative (NCCI) manual was released. The NCCI manual included ambiguous language which many understood to be another attempt by Medicare to distinguish between the appropriate use of the HCPCS G0416-G0419 codes introduced in 2009 for prostate biopsy specimens collected via the transperineal or "saturation" biopsy technique (PSB) and the use of CPT 88305 for reporting prostate needle biopsies collected via the traditional transrectal ultrasound (TRUS) technique. However, a policy update published by Palmetto GBA last week has shed new light on the curious NCCI language, making it clear that it is Medicare's intent to require the use of these new G-codes for all prostate procedures anytime 5 or more separate specimen are billed. This new policy effectively caps reimbursement for all prostate biopsy specimens, irrespective of the manner in which they were collected.

Impact:

Unfortunately, this change does have a significant financial impact as well. The Medicare Physician Fee Schedule National Payment Amount (unadjusted for locality) for G0416 is $670.88, which represents the equivalent of 6.34 units of 88305 (which has a National Payment Amount of $105.86 per unit). Unfortunately, for those who perform PC-only services, the news is worse still.The National Payment Amount for G0416-26 is $182.10, which represents the equivalent of only 5.0 units of 88305-26, which has a National Payment Amount of $36.08 per unit. Therefore, laboratories and physician practices that typically bill for more than 6 specimens for a prostate biopsy case will see their reimbursement for these cases capped at the equivalent of 6.34 units for a global service and 5.0 units for a PC-only service. For a laboratory or pathology practice that has typically billed for 12 specimens for the average prostate case, the Medicare reimbursement will effectively be reduced by 47% on global cases and by 58% for PC-only cases.

History:
As alluded to above, a new set of HCPCS codes (Healthcare Common Procedure Coding System) were introduced by CMS in 2009. HCPCS codes are procedure codes assigned by Medicare and they are used to identify services not listed in the CPT code book. The codes are primarily utilized by the Medicare program, but private payors may also recognize the codes. Instruction from Medicare indicated these codes should be reported when prostate biopsy specimens were collected via prostate saturation biopsy (PSB) technique. PSB procedures are usually performed from a transperineal approach under general anesthesia, using ultrasound technology. This allows the urologist to label each core as to site and creates a map of the precise location of each biopsy. Since this technique results in large numbers of biopsies (typically 30-40"), Medicare wanted to update the established payment policy of reimbursing one unit of 88305 for each separately identifiable core. Therefore, the following HCPCS codes were established for reporting prostate saturation biopsies:
• G0416- Surgical pathology, gross and microscopic examination for prostate needle saturation biopsy sampling, 1-20 specimens
• G0417- Surgical pathology, gross and microscopic examination for prostate needle saturation biopsy sampling, 21-40 specimens
• G0418- Surgical pathology, gross and microscopic examination for prostate needle saturation biopsy sampling, 41-60 specimens
• G0419- Surgical pathology, gross and microscopic examination for prostate needle saturation biopsy sampling, greater than 60 specimens

Do you have a source for this? And an implementation date? This could seriously impact my practice. Thanks in advance.

 

[WEBB PINKERTON]

I hope old Joe Plandowski composes something to inform his "clients" about this. His letter about Urovysion cuts was classic.

 

[pathstudent]

Do you have a source for this? And an implementation date? This could seriously impact my practice. Thanks in advance.

It was an email from our billing company. I would contact your billing company.

I found this link that seems to support the message from our billing company but doesn't have the detailed information found in the email message.


http://www.palmettogba.com/palmetto...rowse by Topic~Lab~8WXT7U5536?open&navmenu=||

 

[LNsquasher]

It was an email from our billing company. I would contact your billing company.

I found this link that seems to support the message from our billing company but doesn't have the detailed information found in the email message.


http://www.palmettogba.com/palmetto...rowse by Topic~Lab~8WXT7U5536?open&navmenu=||

Thanks. Yeah, I also ran across that page on the palmetto site based on searching their website. If true, not a good development for those with prostate business.

 

[pathstudent]

Thanks. Yeah, I also ran across that page on the palmetto site based on searching their website. If true, not a good development for those with prostate business.

I am sure it is true. Our billing company is super on top of CMS guidelines.

Like Adam Ewing wrote in his famous journal from the South Pacific back in the 1800s.

"selfishness in the individual uglifies the soul. Selfishness in society is extinction" The greed based practice of these in-office pathology labs have ruined prostate reimbursement for everyone.

Thankfully they didn't destroy reimbursement for the 88305 across the board.

Remember everyone. Practice ethically. Don't kill the goose laying the golden eggs.

 

[veo1]

This is great news! It seems that most prostate biopsies these days are sent to companies like botswick or are processed in the in-office labs. I hope the pathologists that sold out and agreed to work at these in-office labs and the private groups that agreed to staff these labs enjoy the fallout from this. I hope the same thing happens with GI and dermpath

 

[LADoc00]

This is total game changer. I do NOT think this is good at all, for the record.

This bodes VERY ill for our profession. Regardless of your thoughts about Bostwick etc, the government seems to have no compunction whatsoever to reducing Pathologist income to nothing overnight.

Expect the job market for new hires to suffer accordingly.

 

[pathstudent]

This is total game changer. I do NOT think this is good at all, for the record.

This bodes VERY ill for our profession. Regardless of your thoughts about Bostwick etc, the government seems to have no compunction whatsoever to reducing Pathologist income to nothing overnight.

Expect the job market for new hires to suffer accordingly.

And remember who we have to thank for this.

And what do you expect the CMS to do. Continue to reimburse 1100 to 5000 for these 12 to 50 prostate biopsy cases, when just separating them into Left and Right which costs about 220 and gives more the same info to make a decision.

CMS ain't stupid.

 

[NuckingFuts]

...when just separating them into Left and Right which costs about 220 and gives more the same info to make a decision.

Seriously?? Before subscribing to this notion one ought to be well-aware of the nuances of the processing of a specimen in the histology lab and deriving a ribbon from a paraffin block. It's difficult enough for the average tech to keep a single core relatively flat enough for the pathologist to gauge the entire sample on a 5 micron cut. It is physically impossible to get several cores aligned on an equal plane, aligned enough to consistently get satisfactory cuts that lay out the maximal amount of core real estate for eval.

 

[LADoc00]

Actually if you REALLY want to game system is money is even more now in the TC.

For a 5 cassette G-code, the TC part actually went UP by 30%!

So this will not hurt Bostwick etc as much as you think. They may actually consolidate down and do better margins than ever before.

The people screwed in this are the little guys reading the slides.

 

[KCShaw]

Doesn't make them smart, or quick, either. Unfortunately at least a proportion of the various techniques people use to squeeze extra pennies out of the system are a result of the system squeezing pennies out of the professionals trying to get paid to do the work. It's a tough balance with folks needing income as well as needing to do an adequate job medically, and some have resorted to (ab)using those kinds of external loopholes more than improving their internal efficiency. And that basic fact is not likely to change.

 

[pathstudent]

Seriously?? Before subscribing to this notion one ought to be well-aware of the nuances of the processing of a specimen in the histology lab and deriving a ribbon from a paraffin block. It's difficult enough for the average tech to keep a single core relatively flat enough for the pathologist to gauge the entire sample on a 5 micron cut. It is physically impossible to get several cores aligned on an equal plane, aligned enough to consistently get satisfactory cuts that lay out the maximal amount of core real estate for eval.

Are you NUckingFuts? The solution is obvious. Take each of the six cores from the container with the 6 biopsies of the left side and place one per cassette (i.e. six cassettes). Take the six from the right side container and do the same. Your histotech will be so happy and you will know you are looking at all the tissue.

For those that don't know, pathology specimens are billed by the container and then coded by what's in the container. If the urologist takes 12 prostate biopsies and places them in one container, you get paid 88305X1 (about 35 bucks) for reading it. If the urologist takes 12 biopies and places them in 12 containers you get paid 88305 x 12 (420 bucks).

The CMS global on an 88305 is about 105. The PC is about 35. The TC is about 70. There are adjustments based on where you live determined by cost of living. People in San Francisco and NYC get paid the most I believe.

So now that Urologists and GIs are making money of path they are incentivized to do as many biopsies as possible and maximizing the money by placing them in different containers. Saw a case of "rule out microscopic colitis" where the GI did 15 biopsies and placed them in 15 different containers with a site listed rather than just dumping them all in one container as what is typical. The bill for the patient/government is 15 times as high and offers no additional information. This is why we need to do away with self referral of pathology services.

 

[Autopsy Sweet]

Are you NUckingFuts? The solution is obvious. Take each of the six cores from the container with the 6 biopsies of the left side and place one per cassette (i.e. six cassettes). Take the six from the right side container and do the same. Your histotech will be so happy and you will know you are looking at all the tissue.

For those that don't know, pathology specimens are billed by the container and then coded by what's in the container. If the urologist takes 12 prostate biopsies and places them in one container, you get paid 88305X1 (about 35 bucks) for reading it. If the urologist takes 12 biopies and places them in 12 containers you get paid 88305 x 12 (420 bucks).

The CMS global on an 88305 is about 105. The PC is about 35. The TC is about 70. There are adjustments based on where you live determined by cost of living. People in San Francisco and NYC get paid the most I believe.

So now that Urologists and GIs are making money of path they are incentivized to do as many biopsies as possible and maximizing the money by placing them in different containers. Saw a case of "rule out microscopic colitis" where the GI did 15 biopsies and placed them in 15 different containers with a site listed rather than just dumping them all in one container as what is typical. The bill for the patient/government is 15 times as high and offers no additional information. This is why we need to do away with self referral of pathology services.

While the solution may be "obvious," this solution also requires all of the effort/manpower/materials of the one core in one container method with a fraction of the pay which just cuts in to your bottom line even more. Maybe the better solution is to, in a 12-core situation, have the urologist put two cores per container and therefore be able to bill the full 6 units while not compromising your ability to adequately see the tissue. Properly embedding 2 cores together is harder than a single core, but certainly easier than 3-6 cores per slide.

I completely agree with doing away with self-referral, though.

 

[lipomas]

Where urologists are really going to get screwed is these stupid IMRT machines the big groups are buying and then "referring" their patients for treatment. Reimbursement is huge but going to get a massive cut.

The "practice" of medicine for many physicians these days and for the past 15-20 years has been to get yours while you still can and then get out when that loophole you exploited is closed. It's kind of despicable.

The TC for pathology should not be as profitable as it is. They should be cutting that instead of the PC.