DURING THE NEXT SIX MONTHS, WE WILL WITNESS an intense debate between the pathology profession and the Medicare/Medicaid bureaucracy. This battle will center around the proposed MUEs (Medically Unbelievable Edits) which place restrictions on the units of service per patient per day on key CPT codes widely used in laboratory medicine.

As you will read in our lead story on pages 2-3, news of this proposal only surfaced in mid-December, just as the holiday season kept folks from paying close attention to business issues and government proposals. It is still a matter"under wraps," because confidentiality agreements cover the information about proposed restrictions on service that was distributed by a Medicare contractor to the American Medical Association and medical specialty associations. It is why neither the Medicare program nor recipients of this information have made it public.

What caught the attention of pathologists was the proposal to restrict use of CPT code 88305 to two units of service per patient per day. But that is not the limit of the bad news. The Medicare contractor proposes to place restrictions on approximately 1,200 CPT codes involving anatomic pathology and clinical laboratory services. By itself, the 88305 restriction is a potential hammerblow to pathology because it covers a procedure that makes up as much as 50% of the services performed by some individual pathologists.

As the laboratory industry responds to this ill-conceived Medicare coding initiative, there are no guarantees that the final decisions affecting 88305 and other laboratory CPTs will be satisfactory to the pathology and laboratory community. This will be a major story of 2006 and you can expect to read more about it in the pages of THE DARK REPORT.

For my part, I believe the very fact that Medicare launched a contractor on a project to propose restrictions on service, based on MUE standards, across all medical specialties, represents a more serious threat. Regardless of whether this round of CPT code edits originated because of incompetence, ignorance, or intent to restrain utilization (thereby reducing costs), the fact that some Medicare officials wanted to go down this road is a sign of the growing pressure they face to control spending—and their lack of creativity in how to solve that problem.

Proposed Coding Edits May Restrict 88305 Use

Full range of proposed edits promises bad news for both pathology groups and clinical labs