Pathology/Lab Coding Alert

Answer correctly and capture Medicare bonus pay

Last month our experts gave you a Physician Quality Reporting Initiative (PQRI) coding primer. This month we-ll give you a chance to test your knowledge with a series of questions and answers.
Before you begin, you might want to review the basics in -Pay Attention to Pathology PQRI and Get Medicare Bonus Pay,- in Vol. 9, No. 5, of Pathology/Lab Coding Alert.

Maneuver Participation Boundaries

 Question 1: Does every physician in a pathology practice have to participate in PQRI to get the bonus?

 Answer 1: No. Medicare links PQRI to the physician National Provider Identifier (NPI), so each physician acts independently with respect to PQRI, says Dennis Padget, MBA, CPA, FHFMA, president of DLPadget Enterprises Inc., in Simpsonville, Ky., and publisher of Pathology Service Coding Handbook. -Participation in the PQRI is voluntary physician-by-physician,- Padget says.
 You don't have to worry that nonparticipating physicians in the same group will count against your 80 percent reporting threshold to qualify for the bonus. -Medicare will count only the allowed charges attributable to the participating physicians in a group when calculating the lump-sum bonus,- Padget says.

 Question 2: Can our lab participate in PQRI if we bill only the technical component of anatomic pathology services?

 Answer 2: No. -Only physicians and certain non-physician providers may participate in the PQRI,- Padget says.
 If a hospital or independent laboratory bills only the technical component (TC) of PQRI-eligible colon cancer or breast cancer cases, the lab shouldn't report 3260F.
 Instead: The pathologist who bills the professional component (26, Professional component) separate from the hospital or independent laboratory is eligible to participate in PQRI and report 3260F with the following codes:
- 88307 -quot; Level V -quot; Surgical pathology, gross and microscopic examination, breast, excision of lesion, requiring microscopic evaluation of surgical margins or breast, mastectomy -quot; partial/simple
- 88309 -quot; Level VI -quot; Surgical pathology, gross and microscopic examination, breast, mastectomy -quot; with regional lymph nodes or colon, segmental resection for tumor or colon, total resection.

 Pitfall: See -Reporting PQRI? Independent-Laboratory Pathologists Beware- below to learn how CMS limits PQRI participation of pathologists whom an independent lab employs or contracts with for professional services.

 
Learn the Modifiers

 Question 3: Assuming that the pathologist is participating in PQRI, what should you do if the pathologist doesn't perform the specified quality measure on a colon cancer or breast cancer case that qualifies for PQRI?

 Answer 3: You should still report the case as you would any other PQRI-qualifying case -quot; just remember to include the appropriate modifier to explain why the physician did not perform the measure, says Sandra Pinckney, CPC, coder at CEMS in Grand Rapids, Mich. Medicare will count these encounters toward your physician's PQRI total, Pinckney says.
 -In 2008, physicians receive credit toward the 1.5 percent bonus merely for reporting their claims with quality-codes and modifiers when applicable, even when they don't demonstrate the underlying performance measure in patient records,- Padget says.
 Do this: Report the eligible breast or colon cancer case with Category II code 3260F (pT category [primary tumor], pN category [regional lymph nodes], and histologic grade documented in pathology report). Then append one of the following modifiers to explain why the pathologist didn't complete the quality measure:
 - 1P -quot; Performance measure exclusion modifier due   to medical reasons
 Use this when the pathologist didn't complete a quality measure due to a limiting factor attributable to the medical aspects of the case (such as no residual cancer in a re-excision).
 - 8P -quot; Performance measure reporting modifier -quot;   action not performed, reason not otherwise specified
 Use this modifier 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.

Watch for Missing Measures

 Question 4: How should we report the breast cancer quality measure if the pathologist examines an eligible lumpectomy requiring margin evaluation (88307) but doesn't receive any associated lymph nodes?

 Answer 4: The PQRI coding will depend on whether the pathology report contains information about the pN (regional lymph node) category.
 -If the pathologist reports the pT category (primary breast tumor) and histologic grade, and if pNX also appears in the report, meaning that the lymph nodes were previously removed or simply weren't submitted, the pathologist has met the expected quality-performance measure and can report 3260F by itself, without a modifier,- Padget says.
 On the other hand, if the pathologist fails to report pNX for the case, report 3260F-8P to indicate that the pN category is missing with no reason for the omission provided.

 Question 5: Can a pathologist report the PQRI quality measure for a breast or colon cancer re-excision even if no residual tumor is present?

 Answer 5: -Yes, provided the re-excision specimen meets the CPT and ICD-9 coding parameters prescribed for quality-code 3260F,- Padget says.
 The guidelines state that you should report 3260F -each time- the pathologist performs an examination of a qualifying breast or colon cancer resection. -You don't have to look to see if a certain amount of time has passed between the initial excision and the re-excision -quot; they-re both separately reportable as long as a qualifying CPT/ICD-9 code combination applies to each one,- Padget adds.
 If the pathologist diagnoses no residual primary cancer in the re-excision specimen, follow accepted ICD-9 coding guidelines to determine whether to report the cancer diagnosis from the initial excision (such as 174.8, Malignant neoplasm of female breast; other specified sites) rather than a -history of- code (such as V10.3, Personal history of malignant neoplasm; breast).
 -If you can legitimately report the past cancer diagnosis code for the current re-excision specimen that has no cancer in it, the case still qualifies for PQRI reporting,- Padget says. -However, you will likely need to add modifier 1P to 3260F because the pathologist probably won't be able to report a histologic grade for the re-excision specimen.-
 On the other hand: PQRI doesn't recognize -history of- ICD-9 codes, such as V10.3, for pathologists.

 Question 6: Can we report 3260F for 88307 or 88309 breast cancer cases that involve conditions such as carcinoma in situ or prophylactic resection for a BRCA-positive woman?

 Answer 6: No. PQRI measure 99 for breast cancer only applies to patients diagnosed with primary breast neoplasm. The ICD-9 code must be from the range 174.0-174.9 (Malignant neoplasm of female breast) or 175.0-175.9 (Malignant neoplasm of male breast).
 Assuming the pathologist does not diagnose primary tumor, the ICD-9 code for carcinoma in situ of the breast (233.0, Carcinoma in situ of breast) doesn't meet the required PQRI code range. Nor does the ICD-9 code for a BRCA-positive woman (V84.01, Genetic susceptibility to malignant neoplasm of breast)  -These scenarios demonstrate the key point that just because a breast case qualifies for reporting with CPT 88307 or 88309 -quot; that is, a pathologist conducts an examination for neoplasia -quot; that doesn't automatically mean it's a PQRI case. You have to be able to legitimately report a qualifying ICD-9 code as well,- Padget says.

Don't miss: Although PQRI requires an ICD-9 code from 174.0-174.9 or 175.0-175.9, it doesn't have to be the primary diagnosis. -If the report lists multiple ICD-9 codes for a PQRI breast cancer case, the diagnosis pointer appearing on the quality-code line must reference the ICD-9 code that makes the case a qualifying breast cancer case, and only that diagnosis,- Padget says.