Taking Laboratory Coding for a Spin. Corrie Alvarez, CPC, CPMA, CPC-I, CEDC

Transcription

1 Taking Laboratory Coding for a Spin Corrie Alvarez, CPC, CPMA, CPC-I, CEDC

2 Agenda Overview of Laboratory Discuss Common Laboratory Terms Coding Guidelines Review Drug Testing, Anatomical Pathology Discuss Molecular Pathology and MAAA Testing Proper Use of Common Modifiers Billing and Coding Challenges

3 Laboratory World Competitive and Complex Highly Regulated Departments: Hematology, Immunology, Microbiology, Cytopathology

4 Laboratory Terms Analyte The sample being analyzed. For blood glucose, the analyte would be glucose

5 Laboratory Terms Assay An analysis done to determine the presence and/or amount of a substance in a source. An assay may be done to determine the level of thyroid hormones in the blood

6 Laboratory Terms Aliquot In Latin, terms means some or several. - a portion of a total amount of a solution Qualitative -vs- Quantitative

7 Billing/Coding Guidelines Testing must be ordered by an authorized provider, must be resulted, must be reported. Diagnoses must come from the ordering provider or their authorized designee.

8 Drug Testing Drug Assays Dependent on purpose and type of patient results obtained. Presumptive Drug Class Screening Drug Class A/Drug Class B Chain-of-Custody Definitive Drug Testing

9 Therapeutic Drug Assays Code Series Drug testing performed to monitor clinical response to a known, prescribed medication Examples: Cyclosporine, Digoxin, Phenobarbital, Vancomycin

10 Cytopathology What is Cytopathology? Pap Smears Bethesda System -standard description of results Cervical changes may be called a squamous intraepithelial lesion (SIL), cervical intraepithelial neoplasia (CIN) or dysplasia.

11 Cytopathology SIL is used to describe pap results. CIN and dysplasia are used to describe the actual changes in cervical cells Squamous intraepithelial lesion (SIL) term used to describe pre-cancer changes.

12 Cytopathology Normal (negative) -no signs of cancer or pre-cancer Atypical squamous cells of undetermined significance (ASC-US) - cellular changes are found - most common abnormal result

13 Cytopathology Squamous intraepithelial lesion (SIL) -Abnormal changes found in the cells. Almost always sign of HPV infection. May indicate pre-cancer.

14 Cytopathology LSIL -low grade. Very common. Usually resolves on it s own without treatment. HSIL -more serious. Can lead to Carcinoma in situ. CIS is a severe form of HSIL.

15 Cytopathology Atypical squamous cells (ASCUS) Need further testing if persistent. 4-6 months repeat pap

16 Cytopathology Atypical glandular cells (AGC) -cell changes are seen that suggest pre-cancer of the upper part of cervix or uterus Cancer -abnormal cells may be spread deeper into cervix or other tissues

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23 Incidence of Cervical Cancer In the U.S., it is estimated that: Annually, about 12,990 new cases will be diagnosed with invasive cervical cancer Over 4,120 women will die of cervical cancer

24 Annual Estimated Costs in US The approximate annual cost of cervical cancer is $181.5 million to $393 million The annual approximate cost of cervical cell abnormalities is between $2.25 billion and $4.6 billion

25 Anatomical Pathology Surgical Pathology Decalcification Special Stains Group l Special Stains Group II Consultations Consultations Tissue blocks/frozen sections

26 Surgical Specimens Gross examination Gross and microscopic Successive codes have an increase level of complexity Colon Biopsies: 88304, 88305, 88307, 88309

27 Additional Surg Path Services Decalcification Special Stains 88312, per stain, per specimen Example: 1. One specimen with multiple slides for that specimen, iron stain ordered = x1

28 Surgical Pathology Consults Consult and report on referred slides, prepared elsewhere: Consult and report on referred material requiring preparation of slides: Consult, comprehensive, with review of records, specimens with report: Pathology consult during surgery: 88329

29 Pathology Consultations Pathology Consultation during surgery first tissue block, with frozen section(s), single specimen each additional tissue block from frozen section(s)

30 Molecular Pathology What is it? Medical laboratory procedures involving the analyses of nucleic acid to detect variants in genes that may be indicative of germline (e.g., constitutional disorders) or somatic (e.g., neoplasia) conditions or to test for histocompatibility antigens (e.g., HLA) What does this mean?

31 Terms to Know ACMG American College of Medical Genetics & Genomics ACOG American Congress of OB/GYNs Alleles One member of a pair or series of genes that occupy a specific position on a specific chromosome

32 Terms to Know Deoxyribonucleic acid DNA Analyte A substance undergoing analysis Assay Determination of the amount of a particular constituent of a mixture

33 Terms to Know Analyte A substance undergoing analysis Assay Determination of the amount of a particular constituent of a mixture Deoxyribonucleic acid DNA

34 Terms to Know Gene The biologic unit of heredity, self-reproducing and located at a definite position (locus) on a particular chromosome Germline The sequence of cells in the line of direct descent from zygote to gametes, as opposed to somatic cells (all other body cells). Mutations in germline cells are transmitted to offspring; those in somatic cells are not.

35 Terms to Know Histocompatibility Antigens (HLA) A molecule occurring on the surface of tissue cells that can take several different forms Nucleic Acids The building blocks of living organisms. These allow the transfer of gentic information to be passed from one generation to the next Variants-a deviation from the normal Common Variants-These typically fit the definition of mutation

36 Let s Look at Definition Again Medical laboratory procedures involving analyses of nucleic acid to detect variants in gens that may be indicative of germline (e.g., constitutional disorders) or somatic (e.g., neoplasia) condition or to test for histocompatibility antigens (e.g., HLA) FEEL BETTER???

37 What was the Need? Human Genome Project Completed in billion dollars Medical Ethics

38 MoPath Starting in 2013, MoPath codes were required to be analyte specific Prior to 2013, a stacking CPT method was used reflecting the test methodology only Tier 1 and Tier 2

39 Tier 1 Represents gene-specific and genomic procedures Code selection based on the specific gene being analyzed Gene descriptors according to HUGO

40 Tier 1 Gene name abbreviation is listed first Example: CFTR Full gene name italicized in parentheses second Example: Cystic Fibrosis Transmembrane Conductance Regulator Not all conditions represented Reference guidelines for additional details, instructions and/or definitions

41 Tier 1 9 new codes, 3 revisions were added in 2016 Watch out for exclusions, add on codes and out of sequence codes Example BRCA testing do not report with 81211, 81213, 81214, 81216

42 Tier 2 Consists of 9 CPT codes (17 pages). Not commonly ordered. Rare diseases Arranged by level of technical resources and interpretive work by the physician

43 Genomic Sequencing & MAAA Used as inputs into algorithmic analysis to derive a single result-numeric score/index/probability 81500/81503 Ovarian cancer risk score Endocrinology Diabetes risk score

44 81503 Oncology (ovarian), biochemical assays of five proteins (CA-125, apolipoprotein A1, beta-2 microglobulin, transferrin and pre-albumin), utilizing serum, algorithm reported as a risk score Pre-surgical blood test Evaluates 5 biomarkers (listed above) Single score between 0.0 and 10.0 Established thresholds Higher scores allow the referral to a GYN Oncologist

45 81506 Endocrinology (type 2 diabetes), biochemical assays of seven analytes (glucose, HbA1c, insulin, hs-crp, adiponectin, ferritin, interleukin 2-receptor alpha), utilizing serum or plasma, algorithm reporting a risk score

46 Appendix O Set of administrative codes for MAAA procedures Proprietary name and Clinical Laboratory or Manufacturer Code Descriptor format MAAA without Tier 1 listed here with 4 numbers followed by the letter M. MAAA Unlisted code 81599

47 MAAA AMA does not recommend pricing for these codes Other codes are used for payment of underlying tests on which the MAAA is done No allowable for algorithms.

48 Modifiers Modifier 26 Professional Component Modifier 59 Distinct Procedural Service Modifier 90 Reference (Outside) Testing Modifier 91 Repeat Clinical Lab Test Modifier 92 Alternative Lab Platform Test

49 Billing & Coding Challenges High volume, low dollar Medical necessity edits Client and patient education Federal and state regulations

50 Medicare/Payer MLCP PSA, Total Medicare will only pay for this test for the following conditions: C61, C67.5, C77.4, C77.5, C D07.5, D40.0, D49.5. N13.9, N32.0, N40.0, N40.1 R31.0, R32, R35.1, R39.16 Z85.46 (total of 38 dx codes)

51 Questions?

52 THANK YOU!!