A Clinician s Perspective on Reimbursement of Genetic Technology and Services
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1 A Clinician s Perspective on Reimbursement of Genetic Technology and Services Dr. Marc S. Williams Clinical Geneticist Associate Medical Director Gundersen Lutheran Health Plan
2 Clinician s Perspective Billed services Multidisciplinary evaluation Access to services Problems with current system
3 Clinician s Perspective Procedures Amniocentesis CVS Infusion Evaluation and Management Services (E&M)
4 Clinician s Perspective Procedures Most straightforward for indications and billing. Some insurers may not cover certain indications. Exclusion of genetic tests.
5 Clinician s Perspective Infusion 2004 Drug Improvement and Modernization Act (DIMA). Defines reimbursement for infused drugs and biologicals. Existing drugs 85% of AWP as of 4/1/2003. New drugs 95% AWP. Implications for treatment for Gaucher, Hurler-Schie and Fabry.
6 Clinician s Perspective Evaluation and Managment RVU disparity with procedures. Element based (for now). Family history vs. pedigree analysis. Reimbursement mismatch with time. Pre- and post-encounter time. Profiling
7 Clinician s Perspective RVUs E&M reimbursement 0.04 RVUs /minute Procedures 0.08 RVUs/minute
8 Elements History Possible to have level 4 and not even do family history Physical Exam Elements of dysmorphology exam not recognized as elements Complexity Poorly defined and subject to interpretation
9 Family History Full 3 generation pedigree Use of statistical analysis Bayes theorum Cancer risk models CPT code for pedigree analysis Subsumed into new E&M
10 Time Element Maximum time (level 5) component 60 mins. Genetic encounters not infrequently 2-3 hours face to face. Level 5 not equivalent to 8x level 1(5-10 mins.).
11 Pre- and Post-encounter Not infrequently many hours. Not well captured under CPT system. Modifier codes frequently rejected. Reimbursement doesn t reflect actual time. Coordination of care. Doesn t reflect actual time Frequently rejected
12 Profiling Audit technique Used to adjust charges (usually down-coding) No comparison group Geneticists listed as pediatricians, internists Code profiles different Fraud accusations
13 New and Improved (?) E&M Eliminate elements Clinical scenarios developed by specialty societies to define CPT levels Implementation 2005? Auditing?
14 Multiple Providers Prohibition multiple providers billing same ICD code on same day. First in, only paid Impairs coordination of care, inconveniences patients, decreases quality Billable entity status for Genetic Counselors.
15 Genetic Counselors Not recognized as billable entity Exceptions Washington, Texas, Ohio (pre-hippa) Generally not licensed by state Exceptions Utah, California Restrictions on incident to billing
16 Definition: Incident to Services provided by a health care professional under the supervision of a physician, which are billed under the supervising physician s UPIN
17 If an employee of the physician provides the genetic counseling and that person is not an NP/PA/CNS/CNM [Nurse[ practitioner, Physician s assistant, Certified nurse specialist, Certified nurse midwife] ] (have a payment benefit category in Medicare) then the genetic counseling can only be billed by the physician as an E/M CPT code [CPT[ is an established patient code. The description of the service from the CPT manual is, Office or other outpatient visit for the evaluation and management of an established patient, that may not require the presence of a physician. Usually, the presenting problem(s) are minimal. Typically, 5 minutes are spent performing or supervising these services. The last sentence refers to the physician component of the service, that is, the time spent supervising the genetic counselor.]
18 Genetic Counselor Hospital employed counselors may bill as part of the facility fee. Washington state mandates coverage of genetic counseling and issues billing ID numbers to certified GCs Billing rules in CA and UT still pending
19 Access Impact Systems don t offer genetic counseling as no reimbursement Productivity based reimbursement limits geneticists in private sector Lack of geneticists in health plan networks Referral requirements to see geneticist (gatekeeper)
20 Hope for the Future National Provider ID number (NPI) GCs eligible 3 rd party payers may allow GCs to use as billable entity State initiatives CPT E&A codes for genetic counseling (HCPAC) Research on impact of genetic services on cost and quality of care
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