Pathology

New Jersey Pathologists will soon begin to feel the effect of new balance billing rules lawmakers passed, with intentions of protecting patients from “surprise bills.” On June 1, 2018, New Jersey Governor Phil Murphy signed the “Out of Network Consumer Protection, Transparency, Cost and Accountability Act.” The new law will go into effect on September 1, 2018.  Once the law is in place, patients will have an arbitration resource to dispute balance bills from out-of-network providers.

APS reported to the 2017 MIPS (Merit-Based Incentive Payment System) program on behalf of approximately 700 clinicians and we’re happy to report that all met, or exceeded, the program requirements to avoid a negative payment adjustment in its inaugural year.  Even better, many of our clients earned a perfect score of 100%, earning them the top positive payment adjustment available for the performance year.  Our clients benefitted from the data-mining capabilities of our contracted MIPS qualified registry to ensure they received maximum incentive for their level of participation in the first

APS has experienced claims processing issues for Anthem Ohio denying professional services, stating services paid to another provider/facility.  After calls to Anthem’s claim department and Provider Relations Representatives, we’ve discovered that hospitals are billing their technical component on a CMS 1500 form without a TC modifier.  With the modifier being absent from the claim, Anthem is processing and paying the hospital at a global rate.  This issue has been experienced multiple times across various health systems over recent years.

Have you reviewed your lab’s strategies for HIPAA compliance lately?  Regardless what side of healthcare you’re on – provider, facility, biller, etc.

In February 2018, Assemblyman Ash Kalra (D-San Jose) introduced Assembly Bill 3087 (AB3087) to the California Legislature.  The proposal is intended to curb healthcare costs by imposing price controls on commercial insurance plans.  This bill was backed labor unions and consumer groups, but faced intense opposition from physicians and hospital.  AB3087 would create a state commission for enforcement and oversight, effectively capping payment for all services and creating a model very close to a single payer system.  Thankfully, this was shelved for consideration by the Assembly Appropriaten

As part of its annual update to the Current Procedural Terminology (CPT) code set, bundling will, once again, be demonstrated through the introduction of new codes.  Bundling simply means that services that were previously separately-reported will now be combined into one CPT code.  The determining factor to bundle codes is when the pair has been identified as being performed together 75% or more of the time.

Effective January 1, 2018, CMS created an Exception to its 14 Day Rule for hospital outpatients receiving molecular pathology and advanced diagnostic lab tests that enabled providers performing the tests to bill Medicare directly for the first time.  Previously, payment for the testing was included in the hospital’s reimbursement and the lab would have to seek its portion from the facility.   For the most part this was due to Medicare’s Date of Service (DOS) policy which states that, in general, the pathology DOS is the date the specimen was obtained.  For many molpath tests and ADLTs it’s

Out-of-Network balance billing of patients continues to be a hot topic at the state level in 2018. This occurs when a patient receives out-of-network medical care and is then responsible for a balance much higher than expected. Often times, this balance can cause financial hardships, driving many states to develop legislation to protect patients from these unexpected costs. There are still many states that do not have legislation regulating this practice, but both New Hampshire and Washington are looking at ways to lessen the liability of balance billing.

Each quarter CMS makes updates to Medically Unlikely Edits (MUE’s) for all CPT codes.    The July 1, 2018, MUE list did not just include updates to allowable units for a few Pathology and Laboratory HCPCS (80000-89999), but also the MUE Adjudication Indicator (MAI) for some codes.  To review these changes, please review our White Paper by clicking here.

Particularly noteworthy is the change to the MUE for IHC stains (88341 and 88344) and the MAI associated with each. 

In January 2017, BCBS of South Carolina began incorrectly processing prostate biopsy claims containing more than 6 units of 88305.  Units over 6 were not considered and the carrier instead provided a remark code CO45, which indicates a usual and customary discount per contract.  Failure to report HIPAA compliant denial and remark codes for non-considered units of 88305 prompted electronic payment posting systems to adjust what should have been appealed for payment.

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