Pathology/Lab Coding Alert

Take advantage of reportable measures for breast and colon cancer

The Physician Quality Reporting Initiative (PQRI) has been the buzz in the physician community -- and should be for pathologists this year, too. Why? Because you have a shot at a 1.5 percent bonus on all of your Medicare services for 2008.

Although no quality measures applied to pathology in 2007, CMS implemented two performance standards that pathologists can report in 2008. "Even if you sit out the voluntary program this year, you need to get up to speed for a potentially expanding list of quality measures that could impact your bottom line in years to come," says Dennis Padget, MBA, CPA, FHFMA, president of DLPadget Enterprises Inc., in Simpsonville, Ky., and publisher of Pathology Service Coding Handbook.

Get a Breakdown of the Newest Measures

You likely already comply with the following 2008 PQRI quality measures for pathologists:

- Measure 99: Breast Cancer Patients Who Have a pT and pN Category and Histologic Grade for Their Cancer
Description: Percentage of breast cancer resection pathology reports that include the pT category (primary tumor), the pN category (regional lymph nodes) and the histologic grade

- Measure 100: Colorectal Cancer Patients Who Have a pT and pN Category and Histologic Grade for Their Cancer
Description: Percentage of colon and rectum cancer resection pathology reports that include the pT category (primary tumor), the pN category (regional lymph nodes) and the histologic grade.

Do this: Report compliance with both measures using new CPT Category II code 3260F (pT category [primary tumor], pN category [regional lymph nodes], and histologic grade documented in pathology report).

Overcome omission: Although CPT 2008 includes an appendix of Category II codes and a supplemental Appendix H that serves as a crosswalk to reporting instructions for each measure, 3260F did not make it into the print edition. You can access updated information at http://www.ama-assn.org/go/cpt.

Always Use the Appropriate ICD-9 and CPT Codes

Pathologists don't need to notify Medicare to start participating in the PQRI. Just report quality code 3260F on eligible claims submitted to your Medicare contractor.

That's not all: "Medicare will only recognize and count the PQRI code when you bill it on the same claim with an eligible CPT code and a qualifying ICD-9 code," says Joyce Matola, billing manager for the Center for Cancer and Hematologic Disease in Cherry Hill, N.J.

"Medicare carriers will deny claims that have just the 3260F code on them," Padget says. "Furthermore, you can't amend or correct a paid claim to add the 3260F code; it has to be there the first time you file."

Caution: "Not all colorectal and breast cancer cases qualify for PQRI," Padget says. Report 3260F only when the accurate CPT and ICD-9 codes for the case meet one of the following qualifying combinations:

Breast:

CPT code is -

- 88307 -- Level V -- Surgical pathology, gross and microscopic examination, breast, excision of lesion, requiring microscopic evaluation of surgical margins or breast, mastectomy -quot; partial/simple or

- 88309 -- Level VI -- Surgical pathology, gross and microscopic examination, breast, mastectomy -quot; with regional lymph nodes.

And ICD-9 code is -

- 174.0-174.9 -- Malignant neoplasm of female breast or

- 175.0-175.9 -- Malignant neoplasm of male breast

Colorectal:

CPT code is -

- 88309 -- - colon, segmental resection for tumor or colon, total resection

And ICD-9 code is -

- 153.0-153.9 -- Malignant neoplasm of colon, or

- 154.0 -- Malignant neoplasm of rectosigmoid junction, or

- 154.1 -- Malignant neoplasm of rectum, or

- 154.8 -- Malignant neoplasm of rectum, rectosigmoid junction, and anus; other.

Know the PQRI Modifiers

You-ll need to learn how to use two new modifiers to explain specific actions involved with the PQRI measures you-re reporting:

- 1P -- Performance measure exclusion modifier due to medical reasons

- 8P -- Performance measure reporting modifier -- action not performed, reason not otherwise specified.

"Modifier 1P denotes that the pathologist didn't complete a quality measure due to a limiting factor not under his control, like when the histologic grade isn't in the report because no residual tumor is present in the current specimen" Padget says. "You may read about two other limiting factor modifiers -- 2P for patient objection and 3P for system limitation -- but CMS doesn't allow them for pathologist reporting."

Don't miss: Use modifier 8P when the pathologist doesn't fulfill the quality reporting standard for a qualifying case, but no reason for the omission is evident in the medical report, such as a missing pNX category when lymph nodes aren't present.

Learn How to Nab That Bonus

Some good news is that the 1.5 percent bonus applies to the reporting physician's total Medicare allowed charges, not just those for breast and colorectal cancer cases. "Total" includes all other types of pathology specimens, plus special stain and other services.

"Medicare calculates the bonus based on allowed charges per individual reporting physician NPI, not at the group or lab level," Padget says.

Do this: To get the bonus, you must report PQRI quality code 3260F for at least 80 percent of all qualifying breast and colorectal cancer cases signed out in 2008.

Here's how: In addition to reporting the CPT and ICD-9 codes as you usually would on CMS-1500, also report 3260F (with modifier, if applicable) in field 24D (that's the hard-copy field, but you can report electronically). This must include date of service, place of service, unit count (must be 1), ICD-9 diagnosis pointer, and charge (must be 0.00, or 0.01 if your system can't handle a 0 fee payment), Padget says.

Important reminder: Matola says that you must report all PQRI claims, both CPT code lines and the quality code line, with the individual performing physician's National Provider Identifier (NPI) number.

You get the bonus for reporting, not performing: Even if the pathologist doesn't perform one of the measures, you should still report 3260F-8P for an eligible case under current CMS rules.

"Participating pathologists should report 3260F, 3260F-1P or 3260F-8P for each qualifying breast or colorectal cancer resection case they sign out in 2008 to maximize their potential to receive the 1.5 percent Medicare bonus," Padget says. "CMS is building a database of physician quality code reporting and is willing to pay physicians just to report the codes. Pay-for-performance will come later."

Get in on a big chance to master your PQRI potential: Come let Dennis Padget teach you more and answer your questions at our upcoming live conference. Learn more and sign up at http://www.codingconferences.com/pathology08a.htm.