MARK R. WICK, M.D.
The 2014 CMS fee schedule for medical laboratories has now been issued (1). Despite opposition by the College of American Pathologists and even the American Medical Association, the government has continued to devalue the contributions of laboratory-based physicians to the clinical care of patients. In particular, overall reimbursement for immunohistochemical procedures has been completely revamped, and two new CPT codes in that area—G0461 & G0462—have been added. The latter designations make a distinction between payments for the first immunostain ordered on a particular tissue block (G0461) and any additional stains (billed as G0462) on the same block. Predictably, G0462 payments will be substantially lessened as compared with past reimbursements (2).
The reasons for this change are multifactorial. First, administrators at CMS continue to have little or no knowledge of what anatomic pathologists really do, or how the information they generate is used in clinical care. Second, laboratory tests are easy targets for funding cuts, because they are much more black-and-white than charges for most other clinical procedures. Third, generational changes in anatomic pathology practice have caused a growth in diagnostic tentativeness, and a reflexive dependency on non-morphological analyses (3). Fourth, Medicare & Medicaid are badly-flawed systems, and they do not work any longer (4). In fact, I would be surprised if either of those programs survives for another decade. Finally, a few unscrupulous practitioners in the ranks of pathologists have helped to bring the current reimbursement scourge upon us, by abusing the application of immunostains on a broad scale (5). Indeed, in my consultation practice, it is a rare case indeed that does not arrive with several immunohistochemical preparations already having been done, no matter what the diagnostic question might be.
An initial response to the CMS decisions might be to expand the use of other tests in anatomic pathology that are affected less by the monetary cuts. For example, one could decide to increase the application of tissue stains in the 88312 and 88313 categories as an overarching reaction, in order to recoup lost income. Nevertheless, that approach would be just as unethical as the indiscriminate overuse of immunostains, and it would not work. CMS would certainly identify the emergence of such a practice pattern and penalize pathologists for it.
For now, I suggest the implementation of several steps in response to the above-cited situation:
1. Efforts should be expended to inform our clinical colleagues (surgeons, internists, pediatricians, gynecologists, etc.), health system administrators, and patients that we will no longer have the wherewithal to perform the breadth and depth of tests to which they have become accustomed in anatomic pathology. This will doubtlessly cause a cataclysmic backlash from them, but we all must adapt to the “brave ‘new’ world” of medical practice together.
2. Anatomic pathologists need to pursue a “back from the future” approach to practice, with renewed emphasis on detailed morphological evaluations and the liberal use of collegial consultations between the members of practice groups. We should not forget that, if they are documented, the latter steps do meet the medicolegal onus for “due diligence,” and there is no codified mandate to send difficult cases to extramural consultants instead (6).
3. Laboratory physicians of today must be more attuned to historical methods of practice in anatomic pathology. Just because a procedure is dated, that does not mean that it is useless. Avenues of diagnostic evaluation such as traditional histochemistry and electron microscopy should be resurrected, reevaluated, and refined to meet current needs (7).
4. A stronger emphasis must be placed in the future on evidence-based practice, formal evaluations of the efficacy of diagnostic criteria (8), and assessment of the cost-effectiveness of adjunctive testing in anatomic pathology. We must not continue to do things that do not really work.
1. Anonymous: Details for regulation #CMS1600-P. (http://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/PhysiciansFeeSched/PS-Federal-Regulation-Notices-Items/CMS-1600-P.html) (Accessed 12-9-2013).
2. Ziman B: More bad news for laboratories in CMS proposed 2014 clinical laboratory fee schedule. (E-publication, 7-10-2013) (www.pathologyblawg.com/pathology-news/more-bad-news-laboratories-cms-proposed-2014-clinical-laboratory-fee-schedule/) (Accessed 12-9-2013).
3. Michel RL: Generational differences now reshaping physician attitudes and will likely affect private pathology group practices. (E-publication, 7-24-2013) (www.darkdaily.com/generational-differences-now-reshaping-physician-attitudes-and-will-likely-affect-private-pathology-group-practices-723#ax222n0Omfeju) (Accessed 12-9-2013).
4. Young T: Social Security, Medicare, Medicaid, & Welfare. (www.toddyoung.house.gov/issues/social-security-medicare-medicaid-and-welfare1/) (Accessed 12-9-2013).
5. Wheeler TM: Immunohistochemistry: when do we have too much of a good thing? (Medscape E-publication, 5-6-2010) (www.boards.medscape.com/forums/?128@@.29fdbd13!comment = 1) (Accessed 12-9-2013).
6. Wick MR: Medicolegal liability in surgical pathology: a consideration of underlying causes and selected pertinent concepts. Semin Diagn Pathol 2007; 24: 89-97.
7. Herrera GA, Turbat-Herrera EA: Current role of electron microscopy in the diagnosis of pigmented tumors. Semin Diagn Pathol 2003; 20: 60-71.
8. Foucar E: Classification of error in anatomic pathology: a proposal for an evidence-based standard. Semin Diagn Pathol 2005; 22: 139-146.