Exploring New Billing Codes in the 2018 Medicare Physician Fee Schedule for Clinical Diagnostic Labs
The Medicare Physician Fee Schedule (MPFS) is updated annually to reflect changes in healthcare practices and technology. One area that is closely watched is the billing codes that impact clinical Diagnostic Labs. In 2018, there were several new billing codes introduced that had an impact on these labs. This article will explore these new billing codes and their implications for clinical Diagnostic Labs.
New Billing Codes in the 2018 Medicare Physician Fee Schedule
Molecular Pathology Tier 1 and Tier 2 Codes
One of the significant changes in the 2018 Medicare Physician Fee Schedule was the introduction of new molecular pathology Tier 1 and Tier 2 codes. These codes were designed to better capture the complexity and cost of performing molecular Diagnostic Tests, which are becoming increasingly important in Personalized Medicine.
- Code 81105: Molecular pathology procedure, Level 1 (eg, identification of single germline variant)
- Code 81106: Molecular pathology procedure, Level 2 (eg, 2-10 germline variants or 1 somatic variant)
- Code 81107: Molecular pathology procedure, Level 3 (eg, 11-25 germline variants, 2-10 somatic variants, or sensitivity >0.1%-1%)
Extended Prostate Biopsy Codes
In addition to the molecular pathology codes, the 2018 Medicare Physician Fee Schedule also introduced new codes for extended prostate biopsy procedures. These codes were created to better reflect the increased complexity and time required to perform these procedures compared to traditional biopsies.
- Code 15791: Extended prostate biopsy, any approach (eg, fusion) including image guidance
- Code 15792: Extended prostate biopsy, any approach (eg, fusion) including image guidance; each additional lesion (List separately in addition to code for primary procedure)
New Pathology and Laboratory CPT Codes
Another area of change in the 2018 Medicare Physician Fee Schedule was the introduction of several new pathology and laboratory Current Procedural Terminology (CPT) codes. These codes were developed to address gaps in existing codes and to better capture the services provided by clinical Diagnostic Labs.
- Code 0093U: Oncology (prostate), mRNA, gene expression profiling by real-time RT-PCR of 17 genes, utilizing formalin-fixed paraffin-embedded tissue, algorithm reported as low or high risk
- Code 0095U: Oncology (lymphoma), mRNA, gene expression profiling by real-time RT-PCR of 759 genes, utilizing formalin-fixed paraffin-embedded tissue, algorithm reported as risk score
- Code 0055U: Oncology (prostate), proportion of cells with DNA aberrations (copy number variant or translocation), utilizing next-generation sequencing, formalin-fixed paraffin-embedded tissue, algorithm reported as percent of tumor cells with DNA aberrations
Implications for Clinical Diagnostic Labs
These new billing codes introduced in the 2018 Medicare Physician Fee Schedule have several implications for clinical Diagnostic Labs. Here are some of the key impacts:
Increased Reimbursement for Molecular Testing
The introduction of the molecular pathology Tier 1 and Tier 2 codes means that clinical Diagnostic Labs performing these tests may see increased Reimbursement for their services. These codes are designed to more accurately reflect the complexity and cost of molecular diagnostic testing, which is a growing area of importance in Personalized Medicine.
Better Documentation and Coding for Extended Prostate Biopsies
The new extended prostate biopsy codes provide clinical Diagnostic Labs with better documentation and coding tools for these procedures. By using these specific codes, labs can ensure that they are capturing the full extent of the services they provide and maximize their Reimbursement for these complex procedures.
Improved Reporting of Pathology and Laboratory Services
The new pathology and laboratory CPT codes introduced in the 2018 Medicare Physician Fee Schedule help to improve the reporting of services provided by clinical Diagnostic Labs. These codes address gaps in existing codes and allow labs to more accurately report the services they offer, leading to better documentation and Reimbursement for these critical services.
Conclusion
In conclusion, the introduction of new billing codes in the 2018 Medicare Physician Fee Schedule has had a significant impact on clinical Diagnostic Labs. These new codes, including those for molecular pathology, extended prostate biopsies, and pathology and laboratory services, provide labs with better tools for documenting and coding their services, ultimately leading to improved Reimbursement and more accurate reporting of the care they provide.
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