Making Sense of the Molecular Pathology Coding Changes for 2012

For those of you who have received our summary of the changes in CPT codes for 2012 you might have been somewhat surprised at the 15 page section on Molecular Pathology.  As in previous years, we have attempted to provide you with the detail necessary to begin using the codes and CPT has begun incorporating the specificity of this diagnostic tool into the codes themselves.  This resulted in a rather large volume of CPT additions which now comprise a new section in the laboratory codes.

The basic underlying logic to the codes is that they are two categories (Tiers).  The first category codes (Tier I) are gene specific, meaning that the actual CPT code selected will depend on the specific gene which the test is designed to detect/test.  Generally these are more well known and established and stable testing protocols which are identified.  The second category of codes (Tier II) is for those tests whose specific genes are not listed in the Tier I codes and depend on the actual procedures being performed and the quantity of tested genetic material.  This is a reflection of the science behind molecular pathology that continues to evolve and demands a new way to code those items that are not tightly defined at this time.  By focusing on the methodology used, such testing can be coded and data collected to begin to develop the test’s own Tier I code.

Molecular Pathology represents one of the fastest developing areas of pathology and laboratory medicine and the effort to capture these services adequately in CPT has resulted in the new section for 2012.  We should expect continued refinement of the Molecular Pathology codes in the future; however this year’s change will likely prove to be the most extensive.  

It should be noted that the level of professional involvement to determine sample adequacy and to interpret the results remain only loosely incorporated into the CPT codes.  These codes are clinical pathology codes and are not available to physicians for billing to governmental payers.  As in all clinical pathology, commercial payers may compensate pathologists for their work in support of these services through payment of the professional component of clinical pathology and the codes should be billed with a -26 modifier to those payers.  For governmental payers and other payers who reimburse clinical pathology services globally, compensation must be negotiated with the laboratory performing the tests.                                                 

Overlying all of these coding changes, however, is that Medicare is planning on paying on the old molecular pathology codes during 2012 and asking laboratories to bill for the new codes in addition, so that Medicare can collect data on the new codes, which will presumably be used in pricing the codes in a budget neutral fashion.  It is likely that commercial carriers will emulate Medicare in this process, meaning that, in most cases, the new codes will not be entered into carrier fee schedules with an actual payment rate as most carriers will wait to see what Medicare does with respect to pricing the new codes.

Given the extensive effort that has gone into the development of molecular pathology and its clinical promise, it is heartening to see the discipline rewarded with more appropriate and specific procedural coding.  We will have to wait to see if the pricing reflects the value of the testing itself.