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Despite ongoing challenges, pathologist reimbursement rules take effect.

Medicare's new rules for reimbursing pathologists' "physician" services under the prospective payment system's "unbundling" provisions were scheduled for implmentation beginning March 2.

As that date drew near, the Government and the College of American Pathologists were still busily engaged in efforts to clarify, revise, or kill the controversial regulations.

The CAP was moving on three fronts. First, still active is its lawsuit to block the regs, which in part revise the rules for a Part B-payable consultation and which also say that a physician service is one that "must ordinarily be performed" by a doctor. Oral hearings before the appeals bench were scheduled for Feb. 27.

Second, the pathologists continued to pursue negotiations with Medicare officials on possible compromises in the rules' wording. But despite pressure from Capitol Hill, regulation writers and policy chiefs at the Health Care Financing Administration have resisted proposals to soften the language. To budge, they feel, would be to dull the enabling legislation's goal of reimbursing providers "properly." Changes now could also conflict with the agency's stand in court.

Third, the CAP at press time was facing the prospect that the rules' implementation will occur as scheduled. Accordingly, the pathologists had compiled a list of questions about how carriers should treat a number of hospital-based physician arrangements not clearly addressed in the regulations. In fact, the CAP submitted the list to HCFA in November and still had received no answers by early February.

Additionally, CAP officials were seeking a meeting with Medicare staffers about HCFA's recent directives to its carriers regarding claims payments and interpretations under the new rules.

In January, preparing for the March 2 start-up, the agency had mailed its carriers a memorandum attempting to clarify the new policies for physicians' services reimbursement. This lengthy letter is significant because it addresses questions the carriers themselves raised after reading the initial HCFA guidelines. And although CAP hopes to effect further clarification in some phraseology, the document's instructions are likely to remain essentially intact as the carriers' interpretive tool.

Here is a summary:

* Services qualifying for reasonable charge reimbursement. Included are anatomic pathology services, including histopathology, oral pathology, and cytopathology. Hematology is included "when a physician makes a microscopic evaluation of a peripheral blood smear or bone marrow aspiration to determine the nature of an abnormality identified by a technologist."

These services HCFA reminds the carriers, qualify for reasonable charge reimbursement when they meet the implementing regulations definition of physicians' services, "particularly the criterion that they require performance by a physician."

The letter notes that "routine" cervical and vaginal smears, while the most common services in cytopathology, are not Medicare-covered services. But if the patient's history or diagnosis indicates a smear is necessary, it may be covered. But under Part B? Only if the results are abnormal, requiring a physician's microscopic evaluation, it says.

* Consultations. These may take a variety of forms, but consultations payable under Part B as a reasonable charge "should not be frequent occurrences," the memo emphasizes.

One "level" of Part B-payable consultations could involve a review of a patient's history and medical record along with the laboratory results, it notes.

Another would be "an interpretive consultation." Definition: one of limited duration requiring the exercise of medical judgment in interpreting test findings and furnishing information about the patient's condition directly to the attending physician. The information cannot be the type a nonphysician lab specialist ordinarily could provide.

Generally such a consultation occurs when an attending physician needs to know the meaning of new or unfamiliar tests or batteries of tests when the batteries reveal an unanticipated combination of results." It may also be appropriate in a patient-related emergency, the memo says. Moreover, an interpretive consultation must be requested by the attending physician. "This can be requested at the time the test is ordered," the letter explains.

The memo goes on to draw a clear distinction. "Pathologists frequently establish procedures to review on a sample or other basis the findings and interpretations of laboratory studies as they are reported by automated equipment or nonphysician laboratory specialists. These are an important part of the lab's quality control activities and are payable on a reasonable cost or prospective payment basis as physicians' services to providers."

HCFA also counsels carriers to create "procedures for monitoring the appropriateness" of the tests for which interpretive consultations are provided. It recommends one approach: "Examine the frequency of these claims and the tests on which they are based among comparable hospitals." Comparing the number of claims for such consultations by type of test to the hospitals' records of total tests performed "would provide meaningful indicators."

* Different consultation, different codes? HCFA's memo instructs carriers to use one code for interpretive consultations (brief in nature) and another for more comprehensive types (involving several test results, a patient history, and greater physician input). Adds HCFA: "We are still examining the coding issue and would appreciate hearing of contractors' experiences to date in this area."

* Part B charge services list. HCFA will not compile such a list because medical practice varies from one region to another and a national list "could not reflect these differences," the memo says. Moreover, maintaining such a list would be difficult since additions and deletions would be needed continually. Reason: "Tests that become more familiar to physicians would have to be removed from the list and new tests, for which consultations would be appropriate, would have to be added as they are developed and approved."

Carriers individually can best make the determination about which tests or batteries they believe physicians in their area may have difficulty understanding without consulting with a physician specialist--e.g., pathologist, hemathologist. Carriers' medical staffs, with advice from local specialty groups, should be adequate to the task, the memo says.

"In any case, it should be understood that it is the circumstances in a particular case, i.e., the need for physician involvement, that is controlling the payment decision, not that a particular test is on a list," it states.

* Copies of consultation requests with claims. Carriers shouldn't require them, the letter says. While some carriers may insist on this to familiarize themselves with the types of services and consulting situations on which claims are based, "we believe requiring the documentation is unnecessarily burdensome to both claimants and carriers."

Carriers, however, may request such documentation on a sample basis. HCFA adds, and they should conduct postpayment reviews on-site at hospitals. During reviews, "if the laboratory physician indicates that the request was initially made orally the carrier will rely on timely entries made by the attending physician in the patients' medical records.

"Note, however," the memo continues, "that routine or standing orders for consultations regarding procedures do not meet the criterion for reasonable payment when the consultations are not medically reasonable and necessary."

* No required consultation report format. The written narrative consultation may be in any form that meets the hospital's requirements if it represents good medical practice and is consistent with the format used for consultative reports by other physicians.

It must contain adequate information to demonstrate that the consultant furnished medical judgment rather than the type of information ordinarily provided by a technologist. And it should also contain an explanation of how the consultation related to a test result outside the normal or expected range in view of the patient's condition.

* Part B-payable blood gas studies. Reasonable charge payment is proper when blood gas studies are part of pulmonary function testing and are included in a more complete pulmonary function study, the memo says.

No separate Part B payment is due when the results of the blood gas study are analyzed by the attending physician. Including a doctor in an intensive care unit, as one of many clinical procedures on which he or she bases a diagnosis. "The attending physician receives Part B payment for diagnosing the patient's condition," HCFA reminded.
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Title Annotation:Medicare rule
Publication:Medical Laboratory Observer
Date:Mar 1, 1984
Words:1307
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