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New Palmetto GBA Prostate Billing Guideline: A Foretelling of Healthcare’s Future?

Posted Aug 27 2012 12:00am

This is a guest blog note by Joe Plandowski ( In Office Pathology; IO P) who often writes about reimbursement issues in surgical pathology. --BAF

Grannie over the cliff? Maybe, but she will have to wait for her turn because pathologists are going first! They are being pushed by Palmetto GBA , a subsidiary of BlueCross BlueShield of South Carolina . Palmetto is the nation's largest Medicare administrative services contractor. Medicare administrative services contractors, called fiscal intermediaries and carriers, pay medical claims, provide customer service, educate medical care providers and detect and deter fraud, abuse, and over-utilization in Medicare.

If you don’t know Palmetto by now, you soon will. They are the carrier that ended code stacking of molecular tests. I actually supported that move because code stacking was an unsolvable puzzle, a scheme that only the bureaucrats at CMS could have devised. Molecular test manufacturers didn’t complain because they set the code stacking for their tests and payers followed like lemmings. However, the latest edict by Palmetto is a direct slam at pathologists. It will financially hurt pathologists and you have to wonder what will happen to patient care.

About a week ago, Palmetto dictated that they will not pay for more than 4 individual CPT 88305 codes per case (see: PROSTATE BIOPSY CODING/BILLING GUIDELINES ). If there are more than 4 CPT 88305 codes to be billed per case, HCPCS G0416 is to be used. G0416 breaks even at 5 CPT 88305 codes for pathologists performing only professional component billing. Breakeven is 6.3 CPT 88305 codes for pathologists performing global (professional and technical components) billing.

What about urologists who follow the recommended prostate biopsy standard of practice and collect 12 tissue cores? When those 12 core vials hit the pathology laboratory, what happens? Is the timing of the flawed Mitchell study paid for by the College of American Pathologists and American Clinical Laboratory Association behind Palmetto’s edict? Palmetto issued a directive in January 2012 on saturation biopsies that was restating what everyone thought they knew. Mitchell’s study covering urology ordering patterns from 2005 through 2007 was released in April 2012. In the period studied, the published standard of care for urologists changed from 6 to 11 prostate cores for a prostate biopsy procedure. In August 2012, Palmetto “clarified” their January 2012 directive to include all urology related CPT 88305’s.

The sad part of this story is Palmetto is pitting the urologist against the pathologist. The urologist is expected to take 12 prostate cores. On a professional fee basis, the pathologist is getting paid by Palmetto for only 5 of those cores. There is no cost savings in reviewing multiple slides from a patient. Each tissue specimen has to be prepared on a slide and stained. Each slide has to be read by a pathologist. Each slide stands alone and the pathologist should be paid for his/her services. Yes, we desperately need to control healthcare costs in this country. But, arbitrary decisions by payers are not the way to go. This may be what we are in for in the coming years. If so, heaven help us.

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