The AMA revised the molecular pathology codes in the CPT® Manual in 2012, but at that time CMS did not adopt the codes as it was still debating whether and how to change the reimbursement system for these services going forward. For CY 2013, CMS elected to recognize the codes, which meant it had to finalize how to pay for them. While CMS did not change pamyent for these services under the Clinical Laboratory Fee Schedule (CLFS) despite industry pressure, its change to the new codes means a change in the payments providers can expect this year and in the future.
Successful appeals can actually lead to CMS policy changes. Facilities have been successfully appealing to receive Part B payments after a Medicare review contractor denied a Part A stay as not medically necessary. As a result, CMS is changing its policy on rebilling for Part B services.
The federal government has been pushing hospitals to reduce the number of preventable readmissions. Now it's putting some money behind the initiative by adding two new CPT codes that will allow physicians to bill for care that may help keep patients out of the hospital.
It is an ongoing challenge for case managers to determine whether a patient is more appropriately placed as an inpatient or in observation. Below are some real-life examples provided by Deborah Hale, CCS, CCDS, in the HCPro book Observation Services: A Guide to Compliant Level of Care Determinations.
