Friday, July 24, 2020

Lab Clinical Consultation Codes: Only AMA Code Restricted to a Single Medical Specialty? What's Up?

This July, AMA CPT posted the agenda for Category I AMA CPT new codes and revised codes for the October meeting.  AMA gave stakeholders until July 24 to ask to see any particular code applications and submit a comment.   The next formal chance to comment will be  during the AMA CPT virtual meeting in October.   
  • AMA is proposing to revising the lab clinical consultation codes (80500, 80502) by deleting them and replacing them with 4 more complex new codes, due to the changing complexity of laboratory tests and the increasing need for consultation with clinicians.   
  • I can't say what the text of the 4 proposed new codes is (due to AMA confidentiality) but I can discuss further the current codes (80500, 80502), why they are so strange, and why it's problematic.  
  • A revision should aim to fix the problems I discuss here, but I don't know if it will.

I discussed some of the logistics on July 17 (here).   

Special early calendar for Lab Codes public comment for October 2020 CPT Mtg

The Devil is in the...Preamble

Current codes 80500 and 80502 are for simple clinical consultation review requested by the patient's clinician, and complex consultation including review of patient charts.   80500 is priced at $23 for 13 minutes of provider time and used 100,000 times in 2011, 14,000 times in 2018 (per Part B data).   80502 is priced at $76 and was used 24,000 times in 2011 and 14,000 times in 2018.   

Not to be confused with G0452 (a CMS code) which pays about $20 and was used 95,000 times in 2017 (per Part B data), for "molecular interpretation, by a physician, medically necessary."  This is a molecular interpretation to produce a specific report.

But here's the AMA devil.  

The code text for 80500/502 is just "clinical pathology consultation" (limited or comprehensive).  But the overlying explanatory text states that a clinical pathology consultation is a service, including a written report, RENDERED BY A PATHOLOGIST requiring "medical interpretative  judgment."

To my knowledge, this code, which may be decades old, is the only code found anywhere in the 1,120 page AMA handbook which states that it is restricted to a single medical specialty.   Wow.

Does the Restriction to "Pathologist" Make Clinical Sense?

The restriction doesn't match either CLIA regulations or the Medicare regulations.  It's entirely a creation of the AMA alone.  

CLIA regulations are at 42 CFR 493.1443(b)(3) and state that a laboratory director be a pathologist, a physician with several years of lab training, or a laboratory directory with one of several board-approved credentials found at CMS here.   

For example, a physician may be an MD/PhD, and boarded by the American Board of Medical Genetics and be a credentialed laboratory director as well under CLIA, but it seems he couldn't use 80502 under AMA's rules, because he is not specifically a "pathologist."   

In this example, this MD/PhD boarded physician geneticist and CLIA molecular lab director couldn't consult using 80502 on a complex hereditary gene panel for a complex patient, but any pathologist credentialed 40 years ago in clin chemistry could - the AMA doesn't even require him to be boarded in CP.

What Are Medicare's Regulations?

We stated that AMA's restriction to "pathologist" exceeds Medicare regulations, or has no basis in Medicare regulations, let's look at that. 

42 CFR 415.130 requires that clinical laboratory consultation services, when provided by a physician (no specialty stated) be requested by the patient's physician, related to an abnormal test result, rest in a written report, and require "medical judgment."   Medicare's Claims Manual, Chapter 12, Section 60, recapitulates the language of 415.130 without adding any specialty restrictions.    

NCCI Policy Manual, Chapter 10, states that 80500/80502 should not be added to a "pathology or laboratory service that [already] includes a physician interpretation."   It also states that the codes require "medical judgment" that cannot be exercised by a "laboratory scientist."  

Regarding G0452, the NCCI manual states that this code is for medically necessary molecular interpretations [to produce an initial report] by "an MD or DO."  Again, no specialty is required by CMS.   CAP is aware of this, having written a four-page history of the creation of G0452 online (here), in part, CAP quotes from CMS creation of G0452 (77 FR 68999ff, 11/16/2012, see also 78 FR 74307, 12/10/2013).

Highly Anomalous to Name a Physician Specialty in AMA CPT

AMA doesn't normally name a physician specialty as the sole user of a CPT code.   

  • For example, it's famous that back surgeries like discectomies are performed by either neurosurgeons or orthopedic surgeons.  
  • It's famous that some cardiac procedures are performed either by interventional radiologists or interventional cardiologists.  
Here, genomics consultations with clinicians could surely be performed by CLIA lab directors who are also either physicians boarded as pathologists or physicians boarded as medical geneticists.   The text in the CPT handbook that precedes the actual codes 80500/502 shouldn't limit their use by specialty as it does now.   AMA should simply state that the code is to be used by an appropriate health care provider (HCP).

One Last Problem

In principal, any stakeholder can proposed an AMA CPT code revision by filing appropriate paperwork.  

But there isn't any way to file for a revision of AMA preamble text, which is where the offending language lies here.   This is especially important because HIPAA regulations require that solely the AMA CPT be used for coding and claims communications between providers and health plans in the US.  (45 CFR 162.1002).  The federal monopoly shouldn't be used to build impenetrable walls between one medical specialty and another.


A July 2020 search of the Medicare Coverage Database didn't identify any articles or LCDs about 80500 or G0452.

I've put some of the key documents that are public open access, in an open access zip file in the cloud here.

One workardound for the physician medical geneticists used as an example, would be to use the physician-to-physician internet clinical consult codes (no patient present), 99446-99449, time for 50, 20, 30, and >31 minutes, reviewing medical records and lab studies.  But to the extent this works for the non-pathologist physician consultant, reviewing labs and records, they make 80500-502 redundant because the pathologist also could use codes 99446-99449.  Here.  These new codes "require verbal consent for the interprofessional consultation from the patient/family," which 80500-502 do not, at least, not in writing by AMA.  However, either the 8050X or 9944X codes can generate a copay to the patient.   

9944X codes can be requested "by a treating physician or qualified healthcare practitioner" but provided by "a physician with the appropriate medical specialty."  (CPT 2020 manual).  


Other turf debates include optometry/ophthalmology, psychologist/psychiatrist, and physician anesthesiologist/CRNA (for the latter, a July 2020 update from AMA here).  Anesthesia services are defined as "by or under the supervision of a physician" but specialist is not stated and CRNAs don't have a separate code set.  (There are some quirky modifier rules, here, here, most recent update here (Claims, Chapter 12:140.)