2018 promises to be a year of important changes for pathology, with the introduction of approximately 40 new CPT® codes for labs this year. Multianalyte Assays with Algorithmic Analysis (MAAA) and Genomic Sequencing Procedures (GSP) are both seeing modified codes, while several codes have also been shuffled around in Tiers 1 and 2. Not only that, but CPT® 2018 presents pathologists and coders with a whole new set of codes: Proprietary Laboratory Analyses (PLA). With all the changes, it can be easy for even the most seasoned coder to get turned around in the codebook!
As part of ProfEdOnDemand 2018 Coding Updates Virtual Boot Camp, pathology compliance and coding expert Ellen Garver lays out the myriad pathology and laboratory CPT® and ICD-10-CM changes for 2018 that you’ll want to know about to protect your practice’s financial state.
Pricing Clinical Lab Tests
For years it’s been acknowledged that the pricing system of the Clinical Laboratory Fee Schedule (CLFS) is too rigid and not the most responsive to technological updates. That all has been set to change with the implementation of section 216 of the Protecting Access to Medicare Act of 2014 (PAMA), which took effect the first of this month. Under this section of PAMA, the amount Medicare pays for clinical lab tests will be equal to the weighted median of private payer rates.
Tests paid under the CLFS are typically Clinical Diagnostic Laboratory Tests (CDLT) and Advanced Diagnostic Laboratory Tests (ADLT). Starting this year, ADLTs will have different requirements for payment, as well as for collecting and reporting data. The Center for Medicaid & Medicare Services (CMS) defines an ADLT under PAMA as “a laboratory test that is covered under Medicare Part B and is offered and furnished only by a single laboratory, that is not sold for use by a laboratory other than the original developing laboratory (or a successor owner), and that meets one of the following criteria:
- The test is an analysis of multiple biomarkers of DNA, RNA, or proteins combined with a unique algorithm to yield a single patient-specific result;
- The test is cleared or approved by the Food and Drug Administration (FDA);
- The test meets other similar criteria established by the Secretary.”
Creating New Codes for Better Tracking
In order to pay more accurately for CDLTs and ADLTs, CMS responded to requests by laboratories to create Proprietary Laboratory Analyses (PLA) codes. PLA codes cover not only ADLTs and CDLTs, but also MAAAs and GSPs.
In order to meet the criteria for PLA codes, the American Medical Association (AMA) states that the test must be “commercially available in the United States for use on human specimens and the clinical laboratory or manufacturer that offers the test must request the code.” To request a code, laboratories must simply find and complete the PLA code application on the AMA website.
When coding, it’s important to know which code takes priority. When a PLA code exists for a given proprietary laboratory service, the PLA code takes precedence, and no other CPT® code should be reported in conjunction with, or in place of, the PLA code. To stay updated, coders can look out for the latest PLA codes on a quarterly basis.
Letting Payers Decide Reimbursement
PLA codes do have several advantages. One key advantage is the short amount of time it takes for a PLA code to be approved and active. While it typically takes as long as 18 months for a standard CPT® code to be active, it takes only 3 months on average for companies to obtain a PLA code. This fast access could help laboratories better manage test reimbursement, according to Veracyte Chief Commercial Officer John Hanna.
In spite of the advantages, as with anything new, there will be some wrinkles to iron out. It remains to be seen how these codes will affect laboratory and pathology services this year, and, more specifically, how well they will help labs track the use of their tests for reimbursement purposes. Additionally, payers may vary on the PLA codes for which they are more likely to provide reimbursement without question; older tests with a proven performance record will be much harder to question than newer tests. Because of this, it’s crucial that physicians provide you with full documentation of services provided—and have the latest knowledge of which PLA or other CPT® code to use.
New Year, Changing Codebook
As a coder, you are your practice’s first line of defense when it comes to payment and reimbursement. There’s plenty of misinformation out there, which adds to the confusion of new and revised or deleted codes. And since payers may be wary of accepting new PLA codes, it’s important to have the latest knowledge on where to find these codes in the codebook and what documentation you’ll need to provide in order to submit foolproof claims. Don’t be surprised if payers initially refuse to provide reimbursement for new codes, and check for any rules or exceptions with all your payers. Equipped with all the necessary documentation to back up your claim, you’ll be a high asset to your practice.
