The Happy Life of the Pathology Practice Administrator

2. Practice, Payment and Coding Issues 2004 Or What is Up with CMS ? Nothing is up—hardly nothingNothing is up—hardly nothing

3. Nothing is up—all is down Every year in every way the squeeze gets tighter and tighter Make sure you do not leave anything on the table This talk is presented to help you do that Nothing is up—all is down Every year in every way the squeeze gets tighter and tighter Make sure you do not leave anything on the table This talk is presented to help you do that

4. Objective of this presentation Pathology payment issues The Correct Coding Initiative (CCI) Adverse CMS initiatives Part A and part B issues Coding and pricing of the new technologies Opportunities and threats in pathology practice Overview of The Big Picture We will look at the problems facing us from both the micro view—the nitty gritty issues—affecting pathology services one by one, and we will also look at issues from a more macroscopic perpective : what is the longer term outlook for pathology payment and what are the economic and societal constraints that affect the future of our workWe will look at the problems facing us from both the micro view—the nitty gritty issues—affecting pathology services one by one, and we will also look at issues from a more macroscopic perpective : what is the longer term outlook for pathology payment and what are the economic and societal constraints that affect the future of our work

5. The Wheel of Fortune That all these forces are interrelated I tried to show graphically on this slide . Public policy is on the top of this wheel. What are the perceived societal needs and the resources that society places to satisfy those needs determines the pricing for the goods that society (government and other third arites) wishes to pay. Coding rears its ugly head, because—make no mistake—coding is the mechanism that can delay, accelerate, change the direction of money flow very dramatically. These activities can directly affect the scope of practice, the degree of competiition between providers and affect the economic well being of pathologists. When we hurt—and we have been hurt in many ways through the years—we tend to affect public policy. And our successes or failures in these efforts directly influences coding and pricing, etc. etc. and so wheel of fortune moves on and on. That all these forces are interrelated I tried to show graphically on this slide . Public policy is on the top of this wheel. What are the perceived societal needs and the resources that society places to satisfy those needs determines the pricing for the goods that society (government and other third arites) wishes to pay. Coding rears its ugly head, because—make no mistake—coding is the mechanism that can delay, accelerate, change the direction of money flow very dramatically. These activities can directly affect the scope of practice, the degree of competiition between providers and affect the economic well being of pathologists. When we hurt—and we have been hurt in many ways through the years—we tend to affect public policy. And our successes or failures in these efforts directly influences coding and pricing, etc. etc. and so wheel of fortune moves on and on.

6. Public Policy Medicare Modernization Act 1.5% physician fee increase Five year clinical lab fee freeze Competitive bidding demonstration Oncology fee increases by legislation Section 942: procedures for new test pricing Two year histology granfather extension One year moratorium on PE recalculation New part B reassignment rules MMA to affect the drug industry and to provide a drug benefit, which is talked to cost more than the whole of the Medicare program when it started. I will not spend significant time on all of these bulleted items but it is worh mentionening some of them, since they all affect the wheel of fortune. The fee increase is due to the rebasing of the components of the physician fees, work, geographic factors and malpractice costs. We were saddled with a five year clin lab fee freeze, as a cost of not getting mandated competetive bidding process. If things do not change the clin labs will have had of either steady or downpricing in 19 of the last twenty years. No other component of the industry has had that bad a tratment. In decade from 93-03 per patient expenses for lab are down nearly 10% despite a significant increase in utilization. Comp bill is out for bidding. The FL initiative. Of nterest is the unilateral increase in oncology fees as an adjustment ot the RVUs. By legislative fiat oncology is better off. No objection from the rest of the medical community becuause no one was affected by the land grab. Section 942 TC grandfather—through 2006 Continuing moratorium on recalculation of TC and PE—when it is over in the Jly 2005 rule for 2006 expect a 2% decrease in hospital settings, and somewhat more in Ils Bill also included are new coverages for CV disease, high risk for diabetes people New reassignement rules – the most worrisome part of this for pathologists—to be addressed. MMA to affect the drug industry and to provide a drug benefit, which is talked to cost more than the whole of the Medicare program when it started. I will not spend significant time on all of these bulleted items but it is worh mentionening some of them, since they all affect the wheel of fortune. The fee increase is due to the rebasing of the components of the physician fees, work, geographic factors and malpractice costs. We were saddled with a five year clin lab fee freeze, as a cost of not getting mandated competetive bidding process. If things do not change the clin labs will have had of either steady or downpricing in 19 of the last twenty years. No other component of the industry has had that bad a tratment. In decade from 93-03 per patient expenses for lab are down nearly 10% despite a significant increase in utilization. Comp bill is out for bidding. The FL initiative. Of nterest is the unilateral increase in oncology fees as an adjustment ot the RVUs. By legislative fiat oncology is better off. No objection from the rest of the medical community becuause no one was affected by the land grab. Section 942 TC grandfather—through 2006 Continuing moratorium on recalculation of TC and PE—when it is over in the Jly 2005 rule for 2006 expect a 2% decrease in hospital settings, and somewhat more in Ils Bill also included are new coverages for CV disease, high risk for diabetes people New reassignement rules – the most worrisome part of this for pathologists—to be addressed.

7. The CCI edits CCI edits involve pairs of CPT codes Mutually exclusive, or Codes within codes (components) CCI edits are applied to services billed by the same provider for the same beneficiary on the same date of service Indicators Use –59 Modifier to override edits for mutually exclusive edits First I want to turn the microscope to a major issue facing pathology, and that is the extraordinary interest in CMS to establish edits between codes that will prohibit payment for one of these codes when both of the services are reported. CCI—This is a nationally authoried system of denying payment when in the opinion of CMS the services are duplicative. Either muturally exclusive or component codes. Examples 1. Albumin and microalbumin ` 2, cholesterol in a lipid panel Indicator 1 for the first, 0 for second instnace Modifier: “distinct and independent service” –59 not related to “specimen” Either different dates of service or different rendering physicians do not meet the criteria for bundling. “ First I want to turn the microscope to a major issue facing pathology, and that is the extraordinary interest in CMS to establish edits between codes that will prohibit payment for one of these codes when both of the services are reported. CCI—This is a nationally authoried system of denying payment when in the opinion of CMS the services are duplicative. Either muturally exclusive or component codes. Examples 1. Albumin and microalbumin ` 2, cholesterol in a lipid panel Indicator 1 for the first, 0 for second instnace Modifier: “distinct and independent service” –59 not related to “specimen” Either different dates of service or different rendering physicians do not meet the criteria for bundling. “

8. National Correct Coding Initiative--CCI CMS Contractor AdminiStar Over 500 edits in Path and LM Web site: www.cms.hhs.gov/physicians/cciedits/ All edits are part OPPS for hospitals Recent focus on physician services and new technologies “Our mind is made up” Complaints: fax Neils Rosen,MD (317) 841-4600 Edits are quarterly 140,000 edits within CPT; 500 in Path and Lab Now focus on anatomic path. Especially in the advanced technology area. Producing significant net revenue decreases—and in a number of instances unnoticed by practice managers. No meaningful appeal mechanism Comments are being disreagarded Neils Rosen, MD, FCAP Medical Director Edits are quarterly 140,000 edits within CPT; 500 in Path and Lab Now focus on anatomic path. Especially in the advanced technology area. Producing significant net revenue decreases—and in a number of instances unnoticed by practice managers. No meaningful appeal mechanism Comments are being disreagarded Neils Rosen, MD, FCAP Medical Director

9. CCI edits—clinical labRecent examples 85027/85004: Automated differentials 80061/83721, 82465/83721: Lipids 80074/individual hepatitis antibodies Clinical pathology consults in microbiology Denies 88500 with 87269, 87660 Modifier –91 “Modifier -91 should be appended to laboratory procedure(s) or service(s) to indicate a repeat test or procedure on the same day. “ Examples of new clin lab edits in 2003-04 Many of these do make sense. sen85027—hemogram and platelet ct, auto 85004—auto diff --------------------Lipid panel, LDL chol ;;; Chol +LDL 87269—immunofluorescent id infectious agents, 87660: t. vaginalis by nuclear probe.Examples of new clin lab edits in 2003-04 Many of these do make sense. sen85027—hemogram and platelet ct, auto 85004—auto diff --------------------Lipid panel, LDL chol ;;; Chol +LDL 87269—immunofluorescent id infectious agents, 87660: t. vaginalis by nuclear probe.

10. Recent CCI edits in physician fee schedule Specimens/Smears Frozen sections/Smears Surgical pathology consultations IHC/flow analysis IHC/tumor morphometry ISH/tumor morphometry ISH/cytogenetic codes (88271-75) But what really has turned the attention of the path community is the focus on service which are billed under path B. These have a Big fiancial impact! It will pay to look at your billing database to see the fequency of this activity in the past, to see the financial impact on the bottom line of net revenue. I will comment on all of these seven edits and how these edits are changing on how we think and how we code about these services.It is these edits that have been the primary cause of the significant changes in coding for these services that are about to be unveiled for 2005. But what really has turned the attention of the path community is the focus on service which are billed under path B. These have a Big fiancial impact! It will pay to look at your billing database to see the fequency of this activity in the past, to see the financial impact on the bottom line of net revenue. I will comment on all of these seven edits and how these edits are changing on how we think and how we code about these services.It is these edits that have been the primary cause of the significant changes in coding for these services that are about to be unveiled for 2005.

11. CCI: Specimens/cytology Excludes cytology (FNA and smears) when billed with surgical pathology (88160/2 and 88173 vs 88304/9) when same diagnosis is rendered on same date Modifier overrides: Different provider Different diagnosis Different specimen No active pursuit to change Significant dollars Must use the modifier even if they are on different specimens, because the systems are not able to pick that up. Note that there is no edit for cell block which is permitted by convention and CPT Wordage. No active pursuit to change Significant dollars Must use the modifier even if they are on different specimens, because the systems are not able to pick that up. Note that there is no edit for cell block which is permitted by convention and CPT Wordage.

12. CCI: Frozen sections/cytology-FNA 88329-32/88160-2 or 88173 Edits on same specimen Permits use with –59 modifier CMS challenges full RVU for intraop cytology CMS challenges use of “intraoperative consultation” Includes all of cyto plus Assumption by CMS is that if one uses one technology and does not get to the diagnosis, then does a second procedure—same or other technology—then only the second service counts. Surgery anology. Modifier can be used—if other attribute was examined. Must document what it was and why second procedure performed. Denies cytopath with OR consult .CMS suggested a new code be developed. Unclear where CAP is. Also denies combo with FNA(88173) but FNA is primary code. Modifier OK if different specimens. Issue of duplicate pre and post service work is raised.. . Includes all of cyto plus Assumption by CMS is that if one uses one technology and does not get to the diagnosis, then does a second procedure—same or other technology—then only the second service counts. Surgery anology. Modifier can be used—if other attribute was examined. Must document what it was and why second procedure performed. Denies cytopath with OR consult .CMS suggested a new code be developed. Unclear where CAP is. Also denies combo with FNA(88173) but FNA is primary code. Modifier OK if different specimens. Issue of duplicate pre and post service work is raised.. .

13. CCI: Surgical pathology consultations Initially edits did not permit additional codes to consultation Now special studies allowed with modifier Documentation in the consultant’s report is key Must be sure to document in the consultants’ reportMust be sure to document in the consultants’ report

14. CCI: Flow cytometry 88180 and IHC 88342 CMS Considers services duplicative May use –59 modifier, but document! Different antibodies Challenge to standard practices Challenge to the unit of service (antibody) Coding changes for 2005 Separation of TC codes from PC codes Med necessity—Wold, Becker: to get input from APC. Status? Denies payment for flow when performed with IHC. Bold move. Directly challenges accepted modes for pathology practice. Pathology is reeling from the effect of this edit. APC has been asked to develop some criteria for the medical nexessity of performing both of these services. In fact, CMS challenges the whole concept of pathologist involvement in flow. Aug 15 proposed rulelast year called it “inappropropriate” to report PC. Accused also of inappropriately increasing the number of markers. Suggested that payment of PC per panel of antibodies was more appropriate. The per antibody payment issue has been in the craw of many third party payer Excess marker use Local carrier policies Guideline development 2005 changes are a separate TC only code per marker, and several PC codes at multiple levels of markers. In addition, those procedure in which only one marker is measure (NK killer cells, B cells) isn no longer on the PFS But the issue has not ended here. There is an overall challenge of the concept that this service and other to follow are physician services in the first place. I will talk about that in a few moments when I address the global CMS challenges. Med necessity—Wold, Becker: to get input from APC. Status? Denies payment for flow when performed with IHC. Bold move. Directly challenges accepted modes for pathology practice. Pathology is reeling from the effect of this edit. APC has been asked to develop some criteria for the medical nexessity of performing both of these services. In fact, CMS challenges the whole concept of pathologist involvement in flow. Aug 15 proposed rulelast year called it “inappropropriate” to report PC. Accused also of inappropriately increasing the number of markers. Suggested that payment of PC per panel of antibodies was more appropriate. The per antibody payment issue has been in the craw of many third party payer Excess marker use Local carrier policies Guideline development 2005 changes are a separate TC only code per marker, and several PC codes at multiple levels of markers. In addition, those procedure in which only one marker is measure (NK killer cells, B cells) isn no longer on the PFS But the issue has not ended here. There is an overall challenge of the concept that this service and other to follow are physician services in the first place. I will talk about that in a few moments when I address the global CMS challenges.

15. CCI: IHC/Tumor Morphometry 88342/88358 Denies payment for tumor morphometry by Chromavision™ Result=2004 new code 88361 Result= two codes for 2005 Pricing by PEAC/RUC underway The articulated basis for this was the CMA assertion that the work value for 88358(RVU) was too high for what was being done with Chromavision. Response to this assault was to develop a new code for 88361 for 2004. tumor ICH, quan or semi quan, each antibody. But CMS has indicated that they were still going to deny the automated computerized analysis in this single code. So, for 2005 codes= automated and non automated analysis==have been approved Pricing of the professional aspects of this code based on the amount of physician work is being evaluated and will be undergoing the RUC process. The articulated basis for this was the CMA assertion that the work value for 88358(RVU) was too high for what was being done with Chromavision. Response to this assault was to develop a new code for 88361 for 2004. tumor ICH, quan or semi quan, each antibody. But CMS has indicated that they were still going to deny the automated computerized analysis in this single code. So, for 2005 codes= automated and non automated analysis==have been approved Pricing of the professional aspects of this code based on the amount of physician work is being evaluated and will be undergoing the RUC process.

16.  ISH/Tumor morphometry  Disallows tumor morphometry with ISH (88365/88358) Coding changes underway for 2005 Two codes: for manual and computer assisted techniques ISH morphometry Practice expenses submission to PEAC/RUC Work evaluation submission—failed, re-do necessary ---------------------------- --------------------------------------- -----------

17. CCI: FISH/cytogenetics 88365 vs. 88271-75 Issues raised Two ways to report same service CMS: The sum is lesser than the parts Turf and payment issues Revised 88365 for 2005 CMS regards that 88365 includes all components and all probes. Mol.cyto is each probe and pays more but inclusive service being cheaper that is what CMS goes with. Issues raised Tissue vs. cells—tissue issue Pathologist vs. cytogenecist Better pay in the cytogenetic codes 88365 practices expenses did not include the cost of the probe and CMS was claimng that all probes were included-- Probes, one vs. many Likely outcome: Revised 88365 removing tissue, adding per probe CMS regards that 88365 includes all components and all probes. Mol.cyto is each probe and pays more but inclusive service being cheaper that is what CMS goes with. Issues raised Tissue vs. cells—tissue issue Pathologist vs. cytogenecist Better pay in the cytogenetic codes 88365 practices expenses did not include the cost of the probe and CMS was claimng that all probes were included-- Probes, one vs. many Likely outcome: Revised 88365 removing tissue, adding per probe

18. Challenge of coding for genetic disorders Currently: In situ hybridization codes Molecular cytogenetics codes Molecular microbiology Molecular diagnostics generic codes Multiplex procedures (83901)definition? The future Codes for microarrays Codes for specific genetic disorders Challenges in coding Generic codes priced either at 5.60 or ‘amplification at 23. Interpret at 5.60. Nucleic Acid Extraction $ 5.60 83890 or 83891 Nucleic Acid Probe $ 5.60 83896 Amplification $23.42 83898 x primer pair Fluorescent Detection No Code Interpretation & Report $ 5.60 83912 83901???? Challenges in coding Generic codes priced either at 5.60 or ‘amplification at 23. Interpret at 5.60. Nucleic Acid Extraction $ 5.60 83890 or 83891 Nucleic Acid Probe $ 5.60 83896 Amplification $23.42 83898 x primer pair Fluorescent Detection No Code Interpretation & Report $ 5.60 83912 83901????

19. Genetic Test Coding Modifiers Solid tumor markers Lymphoid/hematopoetic neoplasms Non neoplastic hematology/coagulation Histocompatability Neurologic non neoplastic Muscular non neoplastic Metabolic Dysmorphology diseases Alpha numeric modifiers are specific for the gene mutation in all of these categoriesAlpha numeric modifiers are specific for the gene mutation in all of these categories

20. Valuing costs and workThe RUC challenge The politics of RUC Costs—a microcosting approach Submitted to PEAC/RUC then to CMS Adjusted through a top down process Work—expert panel or Survey process of 30+pathologists Time for the service (intra, pre and post) Ranking of work effort (intensity) NOW we will move away from this microcosm of CCI and begi looking at some more global challenges in codification of our work. The first of these is the challenge of the Relative Value Update Committee- What is Ruc. 29 seats, 3 rotating seats, 20 M annual cap Applies to all services with a professional component Both costs and physician work are submitted for approval Costs-direct costs only Supplies, labor, dedicated equipment—direct costs A microcosting detailed process Work survey has really had some problems not enough people located to be surveyed evaluations all over the place diffficulty with reference services Results have been poor Improving through recrutiment, education, early surveying, hand holding, consultant NOW we will move away from this microcosm of CCI and begi looking at some more global challenges in codification of our work. The first of these is the challenge of the Relative Value Update Committee- What is Ruc. 29 seats, 3 rotating seats, 20 M annual cap Applies to all services with a professional component Both costs and physician work are submitted for approval Costs-direct costs only Supplies, labor, dedicated equipment—direct costs A microcosting detailed process Work survey has really had some problems not enough people located to be surveyed evaluations all over the place diffficulty with reference services Results have been poor Improving through recrutiment, education, early surveying, hand holding, consultant

21. The RUC ChallengeImproving the Process Survey of practice costs Data on “typical” run size, failure rate, etc. Survey of professional work Education by experts Understanding the system Custom reference services Role of department chair Participation of academia is critical! Improving how data is gathered Supposed to be typical Costs--False starts, failed QC, out of limits etc Size of run. Work—bring back those who have had original experience with the RBRVS Proving education —knowing relative worth without coaxing understading of the process )intra, pre and post components in a global fshion)—all components of work Involvement of the academic community is critical in the evaluation of physician work CAP is looking for additonal people to survey—especially for the automated services in tumor morphometry Improving how data is gathered Supposed to be typical Costs--False starts, failed QC, out of limits etc Size of run. Work—bring back those who have had original experience with the RBRVS Proving education —knowing relative worth without coaxing understading of the process )intra, pre and post components in a global fshion)—all components of work Involvement of the academic community is critical in the evaluation of physician work CAP is looking for additonal people to survey—especially for the automated services in tumor morphometry

22. CMS challenges The unit of service The same payment per unit of service The valuation of work (duplication of pre or post service work) Computer assisted image analysis Practice expenses moratorium expires 2005 Global –PC=TC proposal Global –PC=TC proposal

23. This month’s news:CMS moves against pathology Potential for transfer of physician services to the CLFS-- Flow cytometry Tumor morphometry (manual and automated) Affected codes: New five flow codes Revised ISH code New two morphometric analysis codes ISH Public hearing July 26 Call in 877-357-7851 #8402656 What this means that CMS would take control of pricing: gap filling/cross walking that the practice may loose part B payment and try to capture it through part A component www.cms.hhs.gov/events/event.asp?id=50 How did we get there I know that CMS has not been impressed by CAP performance But it may have more to do with the misunderstanding by other professionals, primarily by doctoral scientists that there is no win in moving to CLFS What this means that CMS would take control of pricing: gap filling/cross walking that the practice may loose part B payment and try to capture it through part A component www.cms.hhs.gov/events/event.asp?id=50 How did we get there I know that CMS has not been impressed by CAP performance But it may have more to do with the misunderstanding by other professionals, primarily by doctoral scientists that there is no win in moving to CLFS

24. Defeat the CMS proposal Be aggressive in the five year review Academic surgical pathology consultations Resist CCI attempts to redefine services Continue to codify new services New concepts in surgical pathology practice Consultation ($$) vs. second opinion (QA) Appropriately code procedures Medicare approved screening tests Keep the specialty and our labs intact Where is the $? Sug path consultations—underpaid. By the accession. Access to experts is by cash only. Appears to be legitimate. The Medicare reimbursement and limiting charge limitations do not extend, and have not been extended, to subcontractors of the entity that initially obtained the specimen -- or to any other entity that performs services as a subcontractor to the physician responsible for a patient.  Rather, these limitations apply to the person who performs the initial service for the patient and who bills the end party (i.e. patient, third party payor, relative) for the service.  Microarray: FDA clearance around the cornerMicroarrays Multiplex reactions CGH By function, or by marker? Initial formulation in groups of ten or 100s of markers Sug path consultations—underpaid. By the accession. Access to experts is by cash only. Appears to be legitimate. The Medicare reimbursement and limiting charge limitations do not extend, and have not been extended, to subcontractors of the entity that initially obtained the specimen -- or to any other entity that performs services as a subcontractor to the physician responsible for a patient.  Rather, these limitations apply to the person who performs the initial service for the patient and who bills the end party (i.e. patient, third party payor, relative) for the service.  Microarray: FDA clearance around the cornerMicroarrays Multiplex reactions CGH By function, or by marker? Initial formulation in groups of ten or 100s of markers

25. Challenges in the Scope of Practice CMS initiatives*** Weakening of part A and professional component Pharmacists Pathologist’s assistants Laboratory scientists Our clinical colleagues Not only a challenge from new technology. Part A weakening from new OIG directives about no or token payment Office of Inspector General (OIG), in its June 8 Draft Supplemental Compliance Program Guidance for Hospitals, suggested that, "in an appropriate context," a hospital would not violate anti-kickback laws by failing to compensate a pathologist for the fair market value of administrative or clinical services provided to the hospital. This a step in the wrong direction. Indeed, the CAP believes the guidance language must be strengthened to clearly state: "Token or no payment for Part A supervision and management services in exchange for the ability to bill Part B services, violates the anti-kickback statute." Challenge comes from many corners—from non ohysician health professionals, from other physicians and from ourselves. Pharms—ordering and performing tests NJ—as passed only waived tests on Md Standing order for certain diseases---CA, PA, RI similar PAs= not confrontational: anesthesia radiology examples must be part of the team as part of the team must eat from the same food supply as salaried by hospital presents an imminent danger Most recent Oig DRAFT COMpliance document states that"Whether a particular arrangement with hospital-based physicians runs afoul of the anti-kickback statute," the OIG goes on to say, "would depend on the specific facts and circumstances, including the intent of the parties. That’s a big change from recent wording token or no payment for Part A supervision and management services" may violate federal anti-kickback statutes. Loss in Blue shield Florida law suit Aetna prof component only for medicare recognized –26 services Physician can run a histology lab without CLIA license The POD lab purveyors Physician can then bill for the TC and the PC Consults—is there something wrong with the first pathologist sec ops is an administrative vehicle for correction of error or quality control inhibition of slides prepared elsewhere in code 88321—wish had foresight to delete Not only a challenge from new technology. Part A weakening from new OIG directives about no or token payment Office of Inspector General (OIG), in its June 8 Draft Supplemental Compliance Program Guidance for Hospitals, suggested that, "in an appropriate context," a hospital would not violate anti-kickback laws by failing to compensate a pathologist for the fair market value of administrative or clinical services provided to the hospital. This a step in the wrong direction. Indeed, the CAP believes the guidance language must be strengthened to clearly state: "Token or no payment for Part A supervision and management services in exchange for the ability to bill Part B services, violates the anti-kickback statute." Challenge comes from many corners—from non ohysician health professionals, from other physicians and from ourselves. Pharms—ordering and performing tests NJ—as passed only waived tests on Md Standing order for certain diseases---CA, PA, RI similar PAs= not confrontational: anesthesia radiology examples must be part of the team as part of the team must eat from the same food supply as salaried by hospital presents an imminent danger Most recent Oig DRAFT COMpliance document states that"Whether a particular arrangement with hospital-based physicians runs afoul of the anti-kickback statute," the OIG goes on to say, "would depend on the specific facts and circumstances, including the intent of the parties. That’s a big change from recent wording token or no payment for Part A supervision and management services" may violate federal anti-kickback statutes. Loss in Blue shield Florida law suit Aetna prof component only for medicare recognized –26 services Physician can run a histology lab without CLIA license The POD lab purveyors Physician can then bill for the TC and the PC Consults—is there something wrong with the first pathologist sec ops is an administrative vehicle for correction of error or quality control inhibition of slides prepared elsewhere in code 88321—wish had foresight to delete

26. Clinician survival tool #1 Client billing for AP CEJA: exploits patients Stark law and Medicare anti kickback State fee splitting provisions Legislative Remedies Direct billing—LA, NJ, RI, SC, Anti markup—CA, NV, MI, OR Full disclosure—AZ, CT, MD, ME, PA, TN,VT Fixes are in the states, federal fix is being explored Fixes are in the states, federal fix is being explored

27. Clinician survival tool #2 The POD lab phenomenon Purchased TC can not be marked up If TC is performed, PC can be marked up Histology not a CLIA service New claim reassignment rules for physician services Need not be on premises (“in office’) Contractor in same carrier region Joint and several liability for claims Especailly for medicare pts. Twenty years: cannot purchase both TC and PC and bill. In office exemption: Purchase TC and in office PC. TC-must be reported separately and cannot be marked up if purchased Pod—clinicians enter into contracts with outside managers who set up turn key labs to which the docs send their path specimens Pods try to get past the Stark rules about referrals to labs in which physician has a financial interet Lab is managed by the outside firm which supplies the histo techs and the pathologist. Labs are set up as separate pods within the same space with each pod serving one practice. Talked about at national meetings and active solicitation going on in multiple big city markets Reassignment rule has broad implications to the relationship of pathologists to clinicians., and how industry relates to pathologists. The prohibition on reassinement rules stes that usually only the perfroming physian can bill and be paid , --a doc cannot reassign his right to receive payment to others. . Numerous exceptins. New exception “an entity may bill for a phsycian service that it acquired pursuant to a contract with an indepenent contractr, regardless where the service was provided. . Both TC and PC could be purchased. Especailly for medicare pts. Twenty years: cannot purchase both TC and PC and bill. In office exemption: Purchase TC and in office PC. TC-must be reported separately and cannot be marked up if purchased Pod—clinicians enter into contracts with outside managers who set up turn key labs to which the docs send their path specimens Pods try to get past the Stark rules about referrals to labs in which physician has a financial interet Lab is managed by the outside firm which supplies the histo techs and the pathologist. Labs are set up as separate pods within the same space with each pod serving one practice. Talked about at national meetings and active solicitation going on in multiple big city markets Reassignment rule has broad implications to the relationship of pathologists to clinicians., and how industry relates to pathologists. The prohibition on reassinement rules stes that usually only the perfroming physian can bill and be paid , --a doc cannot reassign his right to receive payment to others. . Numerous exceptins. New exception “an entity may bill for a phsycian service that it acquired pursuant to a contract with an indepenent contractr, regardless where the service was provided. . Both TC and PC could be purchased.

28. The Macro View Economics is the principal driver, value is second Decreasing payment per unit of work Consolidation and regionalization for productivity gain and market clout The stars will shine, the cows will be butchered Be or be-ware the niche player Name branded pathology Stick close to the patient and his physician Embrace new tech, new paths Known facts, Whither pathology? Pathology in the Crossroads Pathology in the Crosshairs---G2 reportsKnown facts, Whither pathology? Pathology in the Crossroads Pathology in the Crosshairs---G2 reports