Issue of “automatic” special stains for GI biopsies

| July 9, 2008
I came across this discussion on a pathologist bulletin board recently.  The original post and responses are from May and I have again scrubbed the names (when used) to protect the innocent. 
What I like about this post is the fact it was started by a pathologist working in a GI POD lab.  This remains a topic of discussion in pathology practice, although their days may be numbered. 
Nevertheless, previous posts on this topic remain one of the most visited pages on this blog and I think this small discussion, largely by pathologists, highlights the issues.  One concern that all of us deal with and we could argue that there is no financial disincentive not to, is the topic of "automatic" special stains in GI biopsies.  Personally, I have not worked anywhere that does this routinely, largely for the reasons below, but realize several labs do, including specialty POD labs, academic and private groups alike.  The other issue of course is the self-referral business and doing more biopsies perhaps than would normally be indicated. 
I’m working in-house for a gastroenterology group as an "independent contractor" pathologist. Before my arrival at the GI office, its pathology operation had been set up by a consultant to maximize income.

I have some ethical and possibly legal/regulatory concerns. First is the matter of whether or not the gastroenterologists might be performing excessive numbers of biopsies, given their financial interest– but this is something over which I clearly have no control.

Of more direct concern to me is the protocol of default performance of special stains on all gastric and esophageal biopsies. Billing for the special stains is "automatic" from the time of specimen accession. Some of these stains I consider so pointless that I just sign them out as "non-contributory".

Questions for Discussion: 1. Do other GI practices also perform specials routinely, regardless of clinical context or H&E findings? 2. Is the automatic performance of special stains best classified as "standard practice", "outlier", or "egregious"? 3. Is the GI group at risk? If so, what are the specific risks, including their odds and magnitudes? 4. Even though I am neither ordering the special stains nor cashing the checks from the patients or insurers, am I at risk?

Response #1 of 4:
Interesting questions. I can’t comment at all on the legal "at risk" issues, but I do know that ordering some stains "up front" on GI biopsies is a pretty common practice in my area of the US. Although I agree that the special stains are often not helpful, it has been advocated by some experts (Montgomery in Biopsy Interpretation of GI Tract Mucosa, for example, recommends upfront ordering of Alcian Blue/PAS for upper GI biopsies although she says it is not essential – see page 1). We don’t get these stains upfront at my county hospital, but many of our local private hospital pathologists do, so I don’t think you are in the "egregious" category…
Response #2 of 4:
Special stains that are not required (noncontributory), but billed, are fraudulent. If you already see the H. pylori with H&E, why the histochemistry? If you already see the specialized intestinal metaplasia, why the histochemistry? If the special stain is not even appropriate (cluster of squames, ulcer bed, obvious carcinoma…) it is totally inappropriate to bill for it.

The G/I pathology in office ancillary services exception to Stark Medicare exception is already under scrutiny by the OIG (in part due to pod labs and specifically the Uropath lawsuit and because of the obvious financial incentive to biopsy once and bill twice) and likely is a cul-de-sac. I suggest you peruse / subscribe to Endoeconomics

The spring 2008 issue suggests that this self referral scheme is not going to be around much longer. Your "colleagues" are already "in," so they will ride this scheme (including you) as long as they can. Speak openly and honestly with your G/I client and lay out your concerns. Tell them in writing that you want to be able to cancel the charge for special stains if it was performed, but non-contributory. If they are worthy of your regard as professionals, they will be amenable to addressing your concerns. If they are not, you should distance yourself from these scoundrels and report them to the OIG for Medicare fraud (and collect your whistle-blower reward) with specific examples that you happen to have handy from systematic inappropriate charges to Medicare patients.

Endoscopists are under compensation assault so they are rapacious. Don’t compromise yourself to offset their financial woes. Do not be part of what is WRONG with American Medicine.

Response #3 of 4:
[Anonymous], a superb answer. The difference between right and wrong is often very clear indeed and if you want to sleep at night…
Response #4 of 4:
A local GI group has an in-house path lab. The members don’t seem sleepy, but are currently doing a prospective study to determine whether or not their biopsy rates have increased since instituting in-house billing. What they’ll do if the results show an increase,(I’d bet on it,) will be interesting. One of their members still argues about the necessity of 6-7 minute cecum-rectum times.

Category: Standards and Guidelines

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