Charles Fiegl
December 2021—Pathologists will have a new set of Current Procedural Terminology codes to use for reporting pathology clinical consultation services, beginning Jan. 1, 2022. These codes, which the CAP developed through its advocacy work with the American Medical Association CPT editorial panel, were published in the final 2022 Medicare physician fee schedule on Nov. 2.
The physician fee schedule published by the Centers for Medicare and Medicaid Services details new payment rates and policies for Medicare Part B services. Every year, the CAP engages with the CMS to protect the value of pathology services included on the fee schedule. The CMS in July released the proposed 2022 fee schedule that included the new codes for pathology clinical consultation services, as well as details on how much pathologists would be reimbursed for their services next year. The CAP commented on the CMS’ proposal and met with agency representatives to address their questions about the payment and other policies for these important new services.
As was the case for 2021, the CMS had projected payments for pathologists and other specialty physicians would be cut in 2022. In the final fee schedule, pathologists will receive an overall cut of four percent unless Congress intervenes as it did in 2020. The CAP has lobbied Congress to mitigate the cuts to pathologists and other physicians, and its specific ask of Congress is to again appropriate an additional $3 billion to the Medicare fee schedule as lawmakers did the year before.
2022 Medicare physician fee schedule relative value units
Members of Congress have demonstrated a willingness to act. Reps. Ami Bera, MD (D-Calif.), and Larry Bucshon, MD (R-Ind.), in October wrote a letter to the leadership in the House of Representatives in support of averting the imminent cuts. The letter was also signed by 245 members of the House. The CAP is urging Congress to act before Jan. 1.
[dropcap]T[/dropcap]he clinical pathology consultation codes (80500, 80502) pathologists have used were identified for review and then referred by the AMA/Specialty Society Relative Value Scale Update Committee (RUC) to the AMA’s CPT editorial panel in October 2019. At the time the descriptions and use of the codes were considered unclear, and the RUC had never reviewed the services. In October 2020, after considering the CAP’s proposal, the CPT editorial panel deleted CPT codes 80500 and 80502 and established four new codes to report pathology clinical consultation and also created guidelines to select and document the appropriate level of service. New codes 80503, 80504, 80505, and 80506 are published in the CPT 2022 code set update, and pathologists can use them to report their services to both Medicare and non-Medicare payers.
The CAP participates and plays a leadership role in the AMA CPT advisory committee and the RUC. In addition, the CAP leads all reviews of pathology services that go before the RUC. Through its role on the RUC, the CAP worked with the CPT editorial panel to establish the new codes and develop new payment rates. On Nov. 2, 2021 the CMS accepted most of the CAP-developed relative values for the pathology clinical consultation services and noted its plan to implement the new codes for Medicare reporting purposes beginning Jan. 1, 2022.
The new CPT coding structure should improve the physician service reporting and billing process for pathologists because the instructions now have a “time” or “medical decision-making” basis for code selection. The distinction among the new code family involves a degree of complexity and/or time of service, broken down by 20-minute increments each for codes 80503, 80504, and 80505, along with add-on code 80506 reflecting an additional 15 to 30 minutes above that spent on CPT 80505 (see “Consultation codes” table). In conjunction with implementing these new services in their practices, pathologists should carefully review the complete set of CPT instructions for using time or medical decision-making criteria to select an appropriate level of service.
The new codes describe four pathology clinical consultation services based on time and complexity. A pathology clinical consultation is a service, including a written report, provided by the pathologist in response to a request (written, electronic, phone, or face-to-face) from a physician or other qualified health care professional, that is related to clinical assessment, evaluation of pathology and laboratory findings, or other relevant clinical or diagnostic information that requires additional medical interpretive judgment. Reporting pathology and laboratory findings or other relevant clinical or diagnostic information without medical interpretive judgment is not considered a pathology clinical consultation.
The CPT codes for pathology clinical consultation services (80503, 80504, 80505, 80506) can be reported when the following criteria have been met:
- The pathologist renders a pathology clinical consultation at the request of a physician or other qualified health care professional at the same or another institution.
- The pathology clinical consultation request is related to pathology and laboratory findings or other relevant clinical or diagnostic information (e.g. radiology findings or operative/procedural notes) that requires additional medical interpretive judgment.
A pathologist can also render a pathology clinical consultation when mandated by federal or state regulation (e.g. Clinical Laboratory Improvement Amendments).
Charles Fiegl is director of the CAP’s advocacy communications, Washington, DC.