Comparative Billing Reports (CBRs) are educational tools administered by the Centers for Medicare & Medicaid Services (CMS). They are developed and disseminated under contract by eGlobalTech (eGT) and its contract partner Palmetto GBA. CBRs are intended for educational purposes only, no reply is necessary, and to identify opportunities for improvement. Starting in January 2014, a CBR was released each month focusing on multiple specialties and procedures.
In August 2014, eGT and Palmetto GBA distributed a CBR, CBR201407, relating to immunohistochemistry (IHC) and special stains. Each CBR compares the providers billing patterns to those of their peers in the state and across the nation for the related Current Procedural Terminology (CPT®) billing codes. CR201407, which focuses on IHC and special stains, includes the following codes: 88305, 88312, 88313, and 88342. Click here to view a sample CBR created for a mock provider.
The CBR focused on billing for the following procedures:
- IHC performed on gastric and combined gastric/colon biopsies;
- Level IV surgical pathology performed on gastric and combined gastric/colon biopsies;
- Special stains group I performed on gastric and combined gastric/colon biopsies; and
- Special stains group II performed on gastric and combined gastric/colon biopsies.
The eGT team evaluated claims data and provided a list of approximately 5,000 Medicare providers of tissue exam by pathologist, special stains, and IHC. These providers were identified as having different billing patterns when compared to their peers.
Why was this topic selected for review?
According to eGT and Palmetto GBA's website, this topic was chosen for three reasons
- To educate providers about the new IHC codes that went into effect in 2014 and the number of units of service to bill for special stains;
- An Office of the Inspector General (OIG) report determined that an increase in the number of tests ordered by physicians contributed to Medicare's payments for lab services increasing by 92% from 1998 to 2008; and
- The OIG July 2014 Report, Questionable Billing for Medicare Part B Clinical Laboratory Services, found that in 2010, over 1,000 labs had unusually high billing for Medicare lab tests
Who can order special stains and IHC?
The CBR201407 FAQ section of eGT's website addresses who can order special stains and IHC Tests.
According to CMS, the treating physician or practitioner must order diagnostic tests and "tests not ordered by the treating physician are not reasonable and necessary."1 However, there is an exception provided for pathology services.
The CMS Benefit Policy Manual states that the pathologist can perform additional tests if the following conditions are met:
- These services are medically necessary so that a complete and accurate diagnosis can be reported to the treating physician/practitioner;
- The results of the tests are communicated to and are used by the treating physician/practitioner in the treatment of the beneficiary; and
- The pathologist documents in his/her report why additional testing was done.
Palmetto GBA educational article on special stains and IHC
Earlier this year, Palmetto GBA posted an educational article on its website relating to the unitization of special stains on gastric biopsies. In summary, the letter states:
- Only the pathologist may determine the medical necessity of a special stain.
- Use of "special stains" is reasonable and necessary in some cases but not others, and specific documentation to justify the need for a special stain is required in the pathology report.
- Based on certain published data, the combined number of gastric biopsies requiring special stains should be equal to or less than 20% of total gastric biopsies received and examined in a given practice, laboratory, or hospital, which providers should self-audit.
- Providers that exceed the 20% threshold may be subject to "additional action."
The College of American Pathology (CAP) issued a formal complaint with CMS regarding the contents of Palmetto GBA's educational article. In the complaint, CAP requested Palmetto GBA remove the educational article from its website. The educational posting has been deleted from Palmetto GBA's website but a copy can be found in the CAP complaint letter.