CAP: Medicare IHC Payment Policy is Inappropriate for Services Provided to Patients

| February 12, 2014

The College of American Pathologists (CAP) has sent a letter to Ms. Clara Marie Smith (CMS) on behalf of Mickey Doyle (MD) in response to the reimbursement cuts now in effect for immunohistochemistry (IHC), essentially claiming that they don’t know anything about IHC services in its version of Kindergarten Coloring – Rules 88342 and 88343 painting the clown face.

Apparently CMS is/was concerned about “current and potential future frequency of immunohistochemical procedures that include multiple, separately identifiable antibodies on the same histologic slide (ie, ‘multiplex antibody stain procedure’)” as a reason for implementing its new payment policy rules for IHC, the CAP summarized in the letter.

What? Holy Cow! As Harry Caray use to exclaim.  This whole thing has to do with multiplexing stains?  Stain cocktails?  3 stains on 1 slide?

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Oh – well that explains everything.  In that case — kill the 88342.  I now agree with CMS and CAP on this.  Replace with G0462.  Got it.

The only problem here is that MOST pathologists don’t actually use IHC stains in this fashion.  In fact, there are a limited number of use cases clinically validated to do so – namely, wait for it, prostate biopsies.  Vis-a-vis Bostwick Laboratories, OURLab and LabMD among others all in the news recently.

Apparently the CAP contacted a major pathology billing company that offered data from 114 pathology groups and the average of all practice cases that used multiplex staining was 3.6%.

Less than 4% of over 100 pathology groups with likely 1000s of pathologists in total actually multiplex!

Bring in the circus music to go with the clown faces…

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The CAP has offered CMS evidence to back its position that the agency should make substantial revisions to Medicare policy responsible for steep reductions to payments for immunohistochemistry (IHC) services.

In a January 27 letter to CMS, the CAP provided data to show new and revised CPT codes, and the codes’ values, should be used to pay for IHC in 2014. In the Medicare physician fee schedule, CMS instead required pathologists to use new Medicare created G codes (G0461 and G0462) to bill for IHC services provided to Medicare beneficiaries starting January 1.

The CAP has strongly opposed the change and spoke with CMS to discuss reversing the policy on January 6. CMS had then expressed concern about “current and potential future frequency of immunohistochemical procedures that include multiple, separately identifiable antibodies on the same histologic slide (ie, ‘multiplex antibody stain procedure’)” as a reason for implementing its new payment policy rules for IHC, the CAP summarized in the letter. The vast majority of these procedures are used in the evaluation of prostate needle biopsies to detect carcinoma.

The instances of multiplex IHC procedures are rare. The CAP analyzed data for a small group of members and found a range of 0% to 6.5%, for an average of 2.2%, of these procedures compared to overall cases. In addition, the CAP contacted a major pathology billing company that offered data from 114 pathology groups and the average of all practice cases that used multiplex staining was 3.6%.

“At this time, we are unaware of evolving technologies that would suggest that significant changes to the clinical utilization of these services will emerge in the foreseeable future,” the CAP stated. “Hence the G code language will result in inappropriate reimbursement for immunohistochemistry, because approximately 96% of services that are currently billed use single antibodies on separate slides and only roughly 4% of services use multiplex antibody stain procedures. With the G codes, only the first antibody per specimen will be billed as G0461. This causes a significant undervaluing of the G0462 in a vast majority of cases when subsequent separate antibodies are applied to a different slide.”

The CAP suggested revisions to the G codes that would eliminate the “misaligned add-on designation of G0462.” CMS requires G0461 to report one unit of service per specimen and G0462 to report each additional stain. The CAP proposed changing the description for G0461 to IHC “or immunocytochemistry, per specimen; each single antibody stain procedure” and G0462 to “each multiplex antibody procedure.”

“The modified G-code structure will provide a mechanism for differentiating the additional work and practice expense of this minority of immunohistochemical procedures, limit the potential migration of additional units of service of the add-on code, and provide a mechanism that will allow a crosswalk from the existing corresponding CPT codes,” the letter stated.

The CAP has additional information on payment policy in its Medicare 2014 Physician Fee Schedule Resource Center, including an in-depth fee schedule webinar presentation available online.

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