81200-81408: Payment Hurdles Postpone New Molecular Diagnostics Codes

Keep using 83890-83914 for most payers.

Don't expect 101 new medical CPT® molecular diagnostics codes to resolve your specificity and payment problems -- CMS has declared that they won't price the codes for 2012.

As Medicare goes, so go most payers. A lot of insurers clearly plan to carry on accepting the "stacking codes" (83890-83914, Molecular diagnostics; ...) in the coming year for tests they cover.

Read on to learn when and how you might start to use the new medical CPT® molecular pathology codes.

Look for CMS Staged Implementation

CMS points out in the 2012 Medicare Physician Fee Schedule (PFS) that the AMA Relative Value Scale Update Committee (RUC) reviewed over 100 new medical CPT® 2012 codes defining molecular pathology services, but they will not be effective for Medicare purposes for 2012.

The novel molecular pathology codes appear in Addendum B to Medicare's PFS final rule with the procedure status indicator of I (Not valid for Medicare purposes. Medicare uses another code for the reporting and payment for these services).

Use ‘Stacking Codes' Now

CMS sates that for CY 2012, Medicare will continue using the existing ‘stacking' codes meant for the reporting and payment for [molecular pathology] services.

That means for Medicare and most other payers, you'll ignore the new codes and report these tests just as you have in past years.

In other words, report molecular assesses using suitable codes from the range 83890-83914. Each code describes a distinct technique, for instance nucleic acid extraction, gene amplification, or nucleic acid probes.

Add them up: You must bill a lone molecular assay by reporting every code (sometimes in multiple units) that defines every step that the lab carries out. As per AMA workgroup, these are stacking codes.

Pitfall: "The stacking code system has some problems," Dettwyler says. "Coders often have difficulty linking the highly technical test protocols to specific codes, resulting in a lack of reporting uniformity. Also, payers often deny the tests because they can't identify the genetic or cancer test."

Although most payers won't take them in 2012, you need to start getting acquainted with the novel molecular pathology codes.

Medical CPT 2012 introduces 92 specific codes for commonly-used genetic markers. The remaining new molecular pathology codes describe resource-based tests not listed in the first group. These are the "Tier 1" and "Tier 2" codes, respectively.

Tier 1: These codes define higher-volume tests for instance breast cancer evaluation for BRCA1 as well as BRCA2, along with genetic cystic fibrosis tests for instance CFTR common variants.

Tier 2: For less-commonly carried out molecular pathology tests, medical CPT® 2012 introduces resource-based codes (levels 1-9). The nine levels signify the range of technical resources along with physician interpretive work needed to carry out a given test.

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