G0461/G0462 damage to CPT coding

Starting on January 1, 2014, the US Centers for Medicare and Medicaid Services (CMS) discarded the American Medical Association’s (AMA) CPT 88342/ 88343 codes proposal per block and replaced it with HCPCS Level II G0461 G0462 codes per specimen. This recent setback for the AMA coding authority goes beyond changes in reimbursements, although this is the most significant issue. The CMS’s decision is also an unfortunate injury to Current Procedural Terminology (CPT) coding in the surgical pathology system, a sort of “collateral damage.”

Established in 1966, CPT coding became incorporated through Health Care Common Procedural Coding System (HCPCS) not only for Medicare beneficiaries, but also for private insurance companies in the 1980s. In 2000, the U.S. Department of Health and Human Services designated CPT as a nationwide standard for reporting medical services. According to Health Insurance Portability and Accountability Act (HIPAA), the CPT data must be used for medical services and procedures rendered to patients by all providers, government payers and insurers. Any manipulation of this well developed and universally accepted coding system should require careful considerations.

HCPCS Level II codes area coding system for medical diagnostic codes, supplies and non-physician services not covered by CPT-4 codes (Level I). Level II codes are composed of a single letter in the range A to V, followed by 4 digits. Level II codes are designated for “Temporary Procedures & Professional Services.” Although among HCPCS Level II are codes P for Pathology and Laboratory, the choice of G codes is closer to CPT coding due to the CPT’s categorization of procedures by professional service.

The use of the G-codes appears to be justified when some changes in methodology could not be adjusted to the existing CPT code practice. Recently (2009) introduced by CMS, the set of G-codes (G0416- G0419) reflects a transperitoneal prostate saturation biopsy method that is different from the traditional transrectal ultrasound (TRUS) technique that remains under the 88305 code.

The codes proposed by CMS (G0461/ Go462) are different. These codes are a replacement of an existing 88342 code. The replacement has resulted in the use of two sets of codes reporting the same procedure, namely the IHC stain. Does this matter? Yes. The presence of double codes erodes the CPT coding system. CPT coding, with all its shortcomings and rigidity, has a rational methodological background for a procedural approach to coding that is essential in surgical pathology. Every brick taken out of the wall of the system weakens the whole structure. Additional G codes mixed with CPT codes bring unnecessary challenges to the institutional LIS.

The CMS has an excuse for pulling the plug due to the American Medical Association’s and College American Pathologists’ (CAP) vacillations. The CMS was on an assignment to cut costs by any means at the time of the practical implementation of the Affordable Care Act on January 1th 2014.

There should be a compromise. AMA/CAP could abandon the block/ slide idea for 88343, but CMS could take 88343 as each additional stain, including the same stain on a different block of the same specimen if diagnostically warranted. The integrity of the CPT coding system would be honored.

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