Thursday, December 24, 2020

CMS Updates Pathology Correct Coding Manual for CY2021

 Medicare has a national Correct Coding Initiative whose rules and policies are binding for Medicare submissions.   (There is a Medicaid initiative as well, which as far as I know, is a perfect mirror of the "Medicare" documents.)  Medicare website here.

The program has three major parts.  One is code-to-code edits, for example, you can't use the code "incision" with the code "appendectomy" since an incision is part of an appendectomy.   The next part is Medically Unlikely Edits, which are volume limits per day per claim.  These represent admninistrative maximum or "stop loss" edits and LCD edits could be lower.   For example, you can't get more than one heart transplant per day or more than one unit of most genetic tests.   Finally, there are a set of Policy Manuals, which are basically arranged by CPT code series (for example, the lab and pathology series 80,000 is Chapter 10).

CMS updated the manuals on December 17, effective January 1, and the pathology manual is here.  See the updates, highlighted by CMS in red, for yourself.  I will highlight some but you are responsible for reading the actual manual yourself.

  • There are minor editorial updates such as referring to deleted codes.  
  • There is a new paragraph around tumor panel codes 81445, 81450, 81455.  
    • CPT codes 81445, 81450, and 81455 describe targeted genomic sequence analysis.  81445 applies to solid organ neoplasm type (5-50 genes) and 81450 applies to hematolymphoid neoplasm type (5-50 genes), while 81455 applies to the number of genes analyzed for either a solid or hematolymphoid neoplasm (51 or greater genes).  Providers/suppliers may not report 81455 with either 81445 or 81450.
    • The above red text seems to be an example of the CCI simply cutting and pasting existing, and here, longstanding, code definitions into the CCI.  It's cryptic why they find this necessary and for just these codes.  The rule about reporting 81455 with the smaller codes is already in the CCI edits and AMA manual. (FN1)
  • Older text, not new, states that the genomic procedures "simultaneously assay multiple genes or genetic regions" and "[do not] report testing for the same gene or genetic region by a different methodology." Adding, "A Tier 1 or Tier 2 molecular pathology procedure code should not, in general, be reported with a genomic sequencing procedure..."
  • There is a section regarding reporting molecular testing for infectious agents on the same day as non-molecular probe testing for infectious agents; see K:2.
I noticed in this year's  Physician Fee Schedule Annual Rulemaking, in sections regarding telehealth, CMS quoted, parsed, and hewed rigorously to the exact phraseology of some AMA CPT paragraphs and definitions (85FR50117ff).  On the other hand, when writing the Correct Coding Manual, CMS notes that its rules are binding on practitioners and may supersede CPT conventions.   So there's a lot to keep track of.


I recently studied CGP codes 81445, '50, '55 and found that most MACs simply do not pay 81455, while between 2018 and 2019, MolDx shifted some lab[s] in its jurisdictions from billing 81455 to billing 81479 for the same service.  Here.