Challenges in Laboratory Coding 2015

INTRODUCTION Laboratory managers and others have long been familiar with the use of Current Procedural Terminology (CPT) codes to identify services provided by the laboratory for billing and reporting purposes. The CPT manual is the property of the American Medical Association (AMA) and is updated annually, including the laboratory section, which encompasses CPT codes 80047-89398.

Until recently, the typical year's update consisted of 10-15 new or modified codes. Updates are announced in early summer, and the Center for Medicare and Medicaid Services (CMS) holds a mid-July meeting each year at which stakeholders present testimony about the new codes and make suggestions as to how they should be priced by CMS. ASCLS Executive Vice President Elissa Passiment attends this meeting to present our views, or alternatively ASCLS submits testimony in writing. Final codes and instructions for their use are published in the fall.

Reimbursement amounts are published near the end of the year with the new Clinical Laboratory Fee Schedule (CLFS). Reimbursement amounts for the CLFS are determined using one of two methodologies: crosswalk or gap fill. Crosswalk matches the new code with an existing code that is deemed to be of similar cost to perform, and assigns that same reimbursement to the new code. Gap fill assumes that the new code is sufficiently different from existing codes to need its own reimbursement determination. Each Medicare contractor decides what its reimbursement will be based on its determination of the cost to perform the test. These different amounts are used for a…

ABBREVIATIONS: CLFS – Clinical Laboratory Fee Schedule, CPT - Current Procedural Terminology, AMA - American Medical Association, CMS - Center for Medicare and Medicaid Services, HCPCS – Healthcare Common Procedure Coding System, NGS - Next Generation Sequencing, MAC - Medicare Administrative Contractor, Mopath – molecular pathology, MUE - Medically Unlikely Edit