Lab industry pushes CMS to withdraw 'highly disruptive' coding changes

Dive Brief:

Clinical laboratory and pathology trade groups have urged the Centers for Medicare and Medicaid Services (CMS) to withdraw certain billing changes that took effect Jan. 1 as part of updates to the National Correct Coding Initiative policy manuals.
Specific issues raised in a letter this week to CMS Administrator Seema Verma include the new instruction that laboratories should only report a single billing code for procedures that produce “multiple reportable test results.” The trade groups said this change and others would "seriously disrupt" aspects of Medicare and Medicaid, criticizing some of the updates as “overbroad and unclear,” and warning they are likely to burden public insurance programs while delaying payments to providers.
Fearing these outcomes, the trade groups are pushing CMS to reverse the changes and consult with industry more thoroughly before making further revisions.

Dive Insight:

The letter authored by AdvaMedDx, the American Clinical Laboratory Association and seven other trade groups is the latest in a series of critical messages the industry has sent to parts of the government. In recent months, other letters have chastised the Government Accountability Office for publishing a “flawed and dangerous” report on the impact of the unbundling of panel test payments and called for CMS to revise its coverage of next generation sequencing (NGS) tests.

The groups address a set of changes to the Medicare and Medicaid policy manuals that came into force at the start of the year. In the organizations’ view, there is a “fundamental disconnect” between current laboratory testing procedures and the changes, some of which they think violate American Medical Association guidance.

Regarding the single billing code issue, the trade groups said they are unsure if batch and multiplex processes are regarded as single laboratory procedures. If that is the case, tests ordered for multiple patients that are processed in a batch would be billed for using a single code. When applied to multiple processes, the ruling could make it hard to know what code to use.

Laboratories currently use specific codes for the different components of these tests but think they would need to file miscellaneous or unlisted procedure codes if only one code is allowed. The trade groups think the implementation of this change will make the billing and reimbursement process slower and more arduous for their members and payers, alike.

“Unless withdrawn, the sweeping approach taken in these updates will seriously disrupt laboratory billing and claims processing by [Medicare Administrative Contractors] and State Medicaid Programs and could require significant revisions to the CPT code set. This does not advance the policies of reducing provider burden and is not in the best interests of Medicare and/or Medicaid beneficiaries,” the trade groups wrote.

The groups have similar concerns about a clutch of other changes, including a ban on the use of multiple component codes when billing for NGS procedures. As the groups see it, that change contradicts guidance about the use of codes to describe genes.

The organizations blamed the issues identified on a lack of opportunity to originally comment on the changes and now want Verma to work with them to put processes in place that address CMS’ concerns with billing without causing “problematic unintended consequences."