In October of 2014, Palmetto GBA proposed a draft LCD that intended to set utilization thresholds on Special Histochemical Stains (Special Stains) and Immunohistochemical Stains (IHC) of 20% on biopsies. This was the Medicare Administrative Contractor’s (MAC) attempt to further drive down reimbursement on CPT codes that have fallen victim to fee schedule reductions, CPT revisions and the “G” code era. This LCD was widely contested by CAP whose stance was that the proposal:
• Purported evidence that lacked credibility and was unsubstantiated.
• Lacked clarity so neither pathologist nor patients are able to prospectively determine if the service is covered.
• Encroached on pathologist medical judgement failing to take into account patient characteristics that vary from practice to practice
• Conflicted with established Medicare program requirements.
Due to contestation by the CAP and multiple other organizations, Palmetto shelved the LCD and continued use of the diagnosis based LCD for IHC and Special Stains. This was until the implementation of ICD-10 in October 2015, when Palmetto and 3 of the 8 other MACs adopted an updated LCD that no longer listed allowed diagnoses but provides coverage indications, limitations and medical necessity policy for Special and IHC Stains. This was discussed in APS’ White Paper acknowledging that Cigna Adopted LCD L35986.
As a recap, the ICD-10 era LCD for these stains first indicates that it is not meant to designate specific stains to be used in differential diagnosis of tissue or neoplasms because this information is readily available in text books and various scientific publications. The policy instead identifies medically necessary criteria for the use of these stains based on claims reviews and overutilization or incorrect billing for the services which includes:
• Reflex templates or pre-orders for Special Stains and/or IHC stains prior to review of the routine H&E stain by the pathologist , or
• Use of Special Stains and/or IHC stains without clinical evidence that the stain is actionable or provides the treating physician with information that changes patient management, or
• Use of added stains when the diagnosis is already known based on morphologic evaluation of the primary stain
The 4 MACs that list this LCD as active on their websites to date are: CGS (L35986), Noridian (L36351), First Coast Service Options (L36234) and Palmetto GBA (L35922). The other 4 MACs will certainly follow suite, although all 8 actively request reports periodically to review to determine payment of these services. With or without the 20% rule included in the LCD, the statement is clear; CMS expects all H&E stained slides reviewed prior to ordering additional stains. Documentation must indicate this review, the ordering of additional stains is medically necessary to providing a complete and accurate diagnosis to the treating physician/practitioner.
APS’ coding team continues to work hard to ensure our client’s compliance and revenue are not at risk through routine coding and documentation audits. As the first year of ICD-10 proceeds, we will continue to monitor this and other LCDs implemented by all MACs and provide necessary feedback to ensure your billing integrity. If you have any additional questions about this, please contact your practice manager.
References:
Centers for Medicare & Medicaid Services. (n.d.) Retrieved from
https://www.cms.gov/medicare-coverage-database/details/lcd-details.aspx?LCDId=35986&ContrId=238&ver=3&ContrVer=2&CntrctrSelected=238*2&Cntrctr=238&s=All&DocType=Active%7cFuture&bc=AggAAAIAAAAAAA%3d%3d&
San Diego, CA