Reimbursement 2005


In This Issue . . .

How preventive medicine, pharmacogenomics, and genetic testing fits into the future lab.

Reimbursement 2005: What to Expect in the Coming Year
A synopsis of the changes in Medicare laboratory reimbursement.

What’s Coming in Point-of-Care Testing
Australia set to conduct nationwide POCT trial; NACB moving toward completion of POCT guidelines.

Reimbursement 2005: What Labs Can Expect In the Coming Year

With a new set of preventive services being covered and more new laboratory tests and technologies entering the market, 2005 could be a challenging year for clinical laboratories on the reimbursement front. In a recent audioconference called “Reimbursement Update 2005,” sponsored jointly by AACC, ACLA, and ASCLS, laboratory reimbursement expert Charles Root, PhD, provided a synopsis of the changes that are ahead in Medicare laboratory reimbursement next year.

What changes in reimbursement will affect your laboratory’s bottom line in 2005? On the positive side, a new preventive services benefit that goes into effect next month will allow labs to begin billing Medicare for certain cardiovascular and diabetes screening tests that are performed under the caveats set forth by the Medicare program. In other areas of laboratory testing, however, codes have been deleted or added in ways that could adversely affect reimbursement.

“There is no question that in the coming years we’re probably going to see continued pressure on laboratory reimbursement, simply because of the size of the nation’s deficit, and I would expect the specter of Congress enacting Medicare laboratory co-payments to be a continuing thorn in the side of the laboratory community, and an issue that must be defeated each year,” opined Charles Root, PhD, President of CodeMap LLC (Barrington, Ill.), a health care consulting company that provides management and advisory services to physicians, hospitals, laboratories, and industry on Medicare reimbursement, regulatory issues, and economic and market trends.

Speaking during “Reimbursement Update 2005,” Root added that the freeze on the Consumer Price Index (CPI) update for Medicare laboratory services has little hope of being lifted any time soon, so labs should expect to be paid at the current reimbursement levels for lab tests, except in cases where codes have been changed. One example of a change that affects reimbursement is in the flow cytometry section of the CPT manual, said Root, where flow cytometry code 88180 (flow cytometry, each cell surface, cytoplasmic or nuclear marker) has been deleted and replaced by five new codes, each of which are reimbursed at levels that are lower than the 2004 reimbursement rates. Although new CPT code 88184, flow cytometry, cell surface, cytoplasmic, or nuclear marker, technical component only; first marker, has an approximate reimbursement rate of $49 this year, and a similar rate of $50.00 in 2005, other new flow cytometry codes will not pay as well as they have in the past. CPT code 88185, flow cytometry, cell surface, cytoplasmic, or nuclear marker, technical component only; each additional marker will only be reimbursed at $24.00 in 2005, instead of the $49.00 rate at which it is now reimbursed. Interpretation of multiple flow cytometry markers is also lower in 2005, sometimes by hundreds of dollars (i.e. CPT 88187 flow cytometry, interpretation; 2 to 8 markers was reimbursed at a rate of $40–$160 in 2004, but providers will receive $69.00 in 2005, and CPT 88188 flow cytometry interpretation; 9 to 15 markers was reimbursed at about $180–$300 dollars in 2004, but will be paid at $86.00 in 2005).

The New Cardiovascular Preventive Benefit

Not all of the lab reimbursement news is that bleak, however. New screening benefits go into effect in January that could bring more revenue into clinical labs. “Medicare seems to be getting into gear to do preventive medicine and pay for it instead of paying after the fact,” said Root. However, he said, all of the new screening benefits have frequency limits, and laboratories should be aware of this. “An ABN is always appropriate when a frequency limit is imposed on a test because you do not know whether the patient has had that test already in the time period it is restricted to,” he advises.

New this year is a screening benefit for cardiovascular disease. “This essentially allows one lipid panel or the three component tests that make up a lipid panel to be performed every five years,” Root explained. “You can either do one lipid panel in the five-year period, or you can do a cholesterol, an HDL, and a triglyceride at any point during the five years as well. You cannot do both, however.”

Unlike previous screening benefits, there is no G code associated with the new cardiovascular screen for 2005. “CMS did not assign G codes to these screening benefits. All they did was say that they are going to handle this through a national coverage determination (NCD),” said Root. “They did come out with revisions to the lipids NCD, which adds the three screening codes that they allowed. All you have to do to get them paid for as a screening benefit is to use those particular ICD-9 codes.” The ICD-9 codes for a screening lipid panel (CPT 80061), total cholesterol (CPT 82465), HDL cholesterol (CPT 83718), and triglycerides (CPT 84478) are: V81.0 special screening for cardiovascular disease, ischemic heart disease; V81.1 special screening for cardiovascular disease, hypertension; and V81.2 special screening for cardiovascular disease, other and unspecified cardiovascular conditions. Medicare appears to assume that one of these three conditions occur if the patient is being screened.

“One issue with the new cardiovascular screen is that LDL is not a covered benefit, so if you automatically reflex to LDL at the same time you perform the other tests, LDL would not be covered,” cautioned Root. “However, once you do have an abnormal result for the screening test, the physician can then request a direct LDL as a diagnostic test because it would be covered on the basis of a high triglyceride level, for example.”

Screening for Diabetes

As of January, Medicare Part B will also cover certain diabetes screening tests after referral from a physician or qualified non-physician practitioner. Only individuals who meet the qualifications set forth by CMS are eligible, so again, using an ABN is advised. In 2005, Medicare will cover two screening tests per calendar year for individuals diagnosed with prediabetes, which
is defined as an impaired fasting glucose level of 100–25 mg/dL or an impaired glucose tolerance level of 140–199 mg/dL 2-hours post glucose challenge. Medicare covers one screening test per calendar year for individuals previously tested who were not diagnosed with pre-diabetes, or who were never tested before. The following tests are covered if all other conditions are met: CPT 82947 glucose, quantitative, blood; CPT 82950 glucose, 2 hours post-glucose, including glucose; and CPT 82851 glucose tolerance tests (GTT), 3 specimens, including glucose. A diagnosis code of V77.1 (special screening for diabetes mellitus) is used to indicate that the purpose of the test is for diabetes screening.

Other Reimbursement Concerns for 2005

During his presentation, Root also described changes to molecular and genetic codes, and noted that HCPCS code G0001 (routine venipuncture for collection of specimen(s) including urine collection by catheter) has been deleted from the Medicare Laboratory Fee schedule and will not be paid after January 1, 2005. Medicare will recognize CPT code 36415 for all routine venipunctures as of January 1, however. Labs should also note that the grace period for use of new codes has been abolished. All codes deleted from the 2004 CPT will no longer be recognized after December 30, 2004, and all new codes must be used beginning January 1, 2005.

New CPT Test Codes and Payment Amounts for 2005

Following are the new CPT test codes for 2005, excluding the molecular diagnostic, genetic testing, and flow cytometry codes. For a comprehensive list of the new lab codes for 2005, and for changes to existing codes, use the AMA’s CPT Manual. The 2005 Medicare National Limitation Amount (NLA) is indicated after each new code.

CPT Code Test Name NLA
82656 PANCREATIC ELASTASE, fecal, qualitative or semiquantitative $16.12
83009 HELICOBACTER PYLORI, blood test analysis for urease activity,
non-radioactive isotope (eg, C-13) $94.11
83630 FECAL LACTOFERRIN, qualitative $16.20
87807 INFECTIOUS AGENT ANTIGEN DETECTION, by immunoassay with direct optical observation; RSV $16.76

The following new electrophoresis codes are used to report procedures requiring specimen concentration:
84166 PROTEIN ELECTROPHORESIS, other fluids with concentration (e.g., urine, CSF) $24.34
86335 IMMUNOFIXATION ELECTROPHORESIS, other fluids with concentration $40.54

New cell count codes:
86064 B CELLS, total count $52.70
86379 NATURAL KILLER (NK) CELLS, total count $52.70
86587 STEM CELLS (i.e., CD34), total count $52.70

Note: CPT code 85046 for reticulocyte counts has been revised to include one or more automated, directly measured parameters. Reimbursement remains the same. 85046 BLOOD COUNT, reticulocytes, automated, including one or more cellular parameters (e.g., reticulocyte Hgb content (CHr), immature reticulocyte fraction (IRF), reticulocyte volume (MVR), RNA content), direct measurement. This code may no longer be reported once for each individual parameter or for calculated parameters.

Source: Charles Root, PhD, CodeMap, LL

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