ACLA Seeks Reversal of NCCI Edit Limiting FISH Reimbursement

A new policy issued by the Centers for Medicare and Medicaid Services (CMS) limiting reimbursement for fluorescence in situ hybridization (FISH) testing to just one procedure regardless of how many probes are used would result in underpayment to clinical and anatomic pathology laboratories, says the American Clinical Laboratory Association (ACLA) in a letter to CMS officials. The letter refers to a change in the National Correct Coding Initiative (NCCI) policy manual that limits reimbursement for FISH testing to one unit of service. Effective Jan. 1, 2014, the NCCI manual states:

The unit of service for in situ hybridization reported as CPT codes 88365, 88367, or 88368 is each probe staining procedure per specimen. If a single probe staining procedure for one or more probes is performed on multiple blocks from a surgical specimen, multiple slides for a cytological specimen, or multiple slides from a hematological specimen, only one unit of service may be performed for each separate specimen. Physicians should not report more than one unit of service for CPT codes 88365, 88367, or 88368 per specimen for a probe staining procedure even if it contains multiple separately interpretable probes.

According to Joanne Glisson, ACLA vice president, reimbursing a laboratory for one procedure, regardless of how many probes must be used for a test, results in inadequate compensation compared to the costs and fails to account for the resources associated with preparing and analyzing each probe in a properly conducted FISH test. “As is reflected in the CPT code descriptors for FISH tests, there is a cost associated with preparation of each individual probe and with the preparation of each slide, both in terms of the technologist’s time and the required materials,” writes Glisson in a March 19 letter. “Purchasing two probes, even if they come together in one vial, typically costs double what it costs to purchase a single probe. “A pathologist or geneticist must analyze each fluorescent probe using single pass filters to determine the number of gene ‘signals’ in each cell; since each probe must be viewed individually, there are no efficiencies to be gained by analyzing all probes at once when the procedure is performed properly,” she continues. “A pathologist or geneticist must then view all of the probes in concern through a filter that can detect all of the relevant colors in order to look for chromosomal abnormalities, interpret the findings, and issue a report.” ACLA is requesting that CMS rescind the NCCI policy, noting that when conducting FISH tests, two or more probes must be used for virtually all patient specimens. Multiple probes are necessary to see almost all chromosomal translocations, duplications, deletions, amplifications, and inversions, says Glisson. Additionally, for some disease tests, multiple probes must be performed on a series of slides due to limitations in the number of fluorophores available. “We understand CMS’s concerns about appropriate utilization of molecular diagnostic tests, and we would not oppose implementation of a reasonable edit that identifies claims submissions for FISH tests that clearly are wrong,” writes Glisson. “However, the NCCI policy is too blunt an instrument for this kind of test, especially because multiple probes are essential to practically all FISH testing.” Takeaway: New NCCI edits limiting Medicare payment for FISH testing to one unit of service results in underpayment and should be replaced with more reasonable edits.   Side Box: CPT Codes and Descriptors for FISH Tests 88365—In situ hybridization (e.g., FISH), each probe (do not report 88365 in conjunction with 88367, 88368 for the same probe). 88367—Morphometric analysis, in situ hybridization (quantitive or semi-quantitative), each probe; using computer-assisted technology. 88368—Morphometric analysis, in situ hybridization (quantitative or semi-quantitative), each probe; manual.