Fraught with complexities, surgical pathology coding remains a tricky task. The CPT© rules and federal regulations that drive the coverage and payments for the services you perform change frequently. Filtering through the options to assign the correct diagnosis and procedural codes and modifiers is daunting at best, and you need to remain in compliance with Centers for Medicare & Medicaid Services (CMS) regulations that constrain coding and billing for your lab and pathology services.
Bottom line: If your lab is not using the most current and specific CPT© and ICD-10 diagnosis codes, you could face huge penalties. Clinical lab managers, pathologists, lab and pathology coders and billers, compliance officers and lab scientists need to understand these codes and changes now.
2018 Quality Reporting and Auditing
Under the Medicare Access and CHIP Reauthorization Act (MACRA), there will be payment opportunities related to quality reporting, as Medicare shifts from a purely fee for service payment model. Dramatic repricing of all clinical lab test codes are in store for next year, including a positive 4-percent payment update for quality reporting to Medicare.
As you gear up for the new year, here are just a few regulatory issues you should hone in on:
- The latest Clinical Laboratory Fee Schedule pricing, including annual public meeting outcomes and results from the Protecting Access to Medicare (PAMA) lab data analysis
- Updates to the Health Insurance Portability and Accountability Act (HIPAA)
- National Correct Coding Initiative (NCCI) Policy Manual 2018 changes
- Medicare Physician Fee Schedule (MPFS) final rule pricing and regulatory impact
Additionally, in 2018, expect to prepare your lab for any further payment updates or reporting requirements as fallout from the PAMA clinical lab test repricing. And CMS is set to release its final rule implementing MACRA any day now.
Internal Audit Example
If getting up to speed on regulatory changes isn’t enough, you also need to be mindful of the potential your practice has of being audited. Both internal and external audit processes need to be addressed, as the former helps to prepare you for the latter. Internal audits also help you avoid problems to begin with.
One way to approach internal auditing for pathology practices, according to a recent United States and Canadian Academy of Pathology presentation, is to take the following steps:
- Audit all pathologists based a 10-case sample
- Use a point system to evaluate coding and documentation errors, with a higher number being assigned to more severe errors
- Depending on the scale, set a pass/fail number
- Each physician’s audit score determines two things: the type of education he or she receives, and the schedule for the next audit
- Provide the physician with the results and meet in person about it
Pathology audits can be overwhelming and intimidating when you don’t know what to expect. But if you make it a priority now to understand the differences between internal and external pathology and clinical laboratory audits, including all the basics, steps, what to expect and what to keep track of, you’ll be ready to develop your own compliance plan.
2018 CPT© and ICD-10 Changes
New and revised 2018 CPT© and HCPCS Level II codes will impact your lab test reporting. Pathologists often assign diagnoses based on findings from procedures such as tissue exams, and clinical labs must use current ICD-10 codes for diagnoses established by the ordering physician to demonstrate medical necessity. In order to accurately code diagnoses from your pathology reports you need to know changes to ICD-10-CM, as well as what documentation is necessary to support the various new codes, to ensure you file clean claims and earn the pay your lab deserves.
Changes on the horizon include:
- Nearly 40 new CPT© codes for labs next year—from microbiology and immunology to myriad new molecular codes—including Tier 1, Genomic Sequencing Procedures (GSPs), and Multianalyte Assays with Algorithmic Analyses (MAAAs)
- CPT© 2018 introduces a new group of codes called Proprietary Laboratory Analyses (PLAs), and new codes for Human Platelet Antigen genotyping
- Zika and respiratory syncytial virus nucleic acid tests are on their way
- Chest and abdominal xray codes have changed to reflect the number of views
Think about it: When a specimen is found to be benign, that’s good news for the patient. So, what’s the best way to produce “benign” coding claims in 2018 that are error-free, fully-reimbursable, and, therefore, good news for your pathology/lab practice? The answer: 2018 coding education.
Get the Latest Coding Updates
Coding experts Ellen Garver and Peggy Slagle guide you through the pertinent 2018 pathology/lab CPT© and ICD-10 changes in their four sessions for ProfEdOnDemand’s 2018 Coding Updates: Virtual Boot Camp. In their sessions, Ellen and Peggy explore new and revised 2018 CPT© and ICD-10 changes for 2018, so you can learn ahead of time what auditors will be looking for if they decide to review your claims. They explain the various surgical pathology and clinical laboratory auditing steps—including how to develop a compliance plan—and how to comply with all the CMS regulations so you can get paid for your services.