Mastering Medical Billing for Clinical Pathology?Labs: Best Practices to Maximise Revenue

What is Clinical Pathology?

Clinical Pathology labs are the medical field that is concerned with examining diseases, their causes, and their effects on the human body. It plays an imperative role in the diagnosis, prognosis, and treatment of various medical conditions. Pathologists are physicians who specialize in pathology. They are often called “doctor’s doctors” because they collaborate with other medical professionals to diagnose and understand diseases. Their expertise extends to various subspecialties within pathology. For instance, their expertise includes explicitly anatomic pathology and clinical pathology labs.

Types of Clinical Pathology Labs

Clinical Pathology labs are specialized facilities where diagnostic tests and examinations are conducted to identify diseases. Understanding the different types of pathology labs helps adapt the diagnostic approach to specific medical needs. For instance, microbiology labs are essential for identifying bacterial/viral infections, and molecular genetics labs are crucial for detecting genetic mutations associated with inherited diseases. The following are four types of clinical pathology labs.

Microbiology Laboratory

Microbiology laboratories are dedicated to conducting tests on bacteria or viruses. This is done with the purpose of determining the presence of infections within the body. These tests play a crucial role in diagnosing specific diseases like tuberculosis (TB) and other infectious conditions.

Molecular Genetics Laboratory

In a molecular genetics laboratory, doctors analyze DNA to detect genetic mutations within the body. These tests are instrumental in diagnosing various diseases by assessing genetic factors. For instance, primary conditions include cancer and Down syndrome. It is imperative to note here that many clinical pathology labs operate privately, while some hospitals also house their own labs capable of conducting these tests.

Histopathology Testing

This involves the collection of samples from the body. These samples are then examined under a microscope to detect potential cancerous indicators. Such testing can be performed on tissue samples obtained during surgical procedures or biopsies.

Cytology Laboratory

Cytology laboratories are medical facilities where healthcare professionals collect samples from the body and subject them to microscopic analysis. The objective here is to identify any signs of infection. Such examinations are generally carried out on swabs taken during medical examinations or biopsies.

Reimbursement Challenges in Clinical Pathology Lab Medical Billing

In an effort to reduce national healthcare expenditures, several changes have been introduced. These changes will certainly have adverse effects on clinical pathology labs reimbursements. Consequently, they will be impacting the profitability of clinical pathology lab facilities. There are three significant changes on the horizon that will pose challenges to the reimbursement of clinical pathology lab medical billing. These include the discontinuation of the TC Grandfather Clause, alterations in Molecular Pathology CPT Codes, and an overall reduction in payments to the clinical pathology labs.

In light of these reimbursement cuts, clinical pathology labs must seek solutions. These solutions should provide swift access to essential data, including quality, operational, clinical, and financial information. This facilitates informed decision-making at the end of the healthcare provider. A proactive approach to clinical pathology lab management is imperative to secure the future success of clinical pathology lab service providers. There are key challenges that will potentially have adverse effects on clinical pathology lab medical billing and coding practices:

Dropping Reimbursements

It has been observed that after facing the downward pressure on reimbursements, clinical pathology labs are exploring cost-cutting measures and improvements in operational efficiency. One approach that can have a considerable impact on the efficiency of the labs is the adoption of a business intelligence (BI) solution. clinical pathology labs are facing the challenge of enhancing quality and expanding service delivery while precisely trimming unnecessary expenses. For that reason, leveraging a laboratory-specific business intelligence platform has become a matter of great concern. There are medical billing companies like Ensure MBS that help in cutting extra costs and empower clinical pathology labs to identify key opportunities for clinical, financial, and operational improvements in clinical pathology lab medical billing and coding.

Clinical Pathology Labs Payment Rates

It has also been observed that substantial changes in clinical pathology labs medical billing and coding have drastically impacted clinical pathology laboratory payment rates. For instance, in previous medical billing updates, a 2.95% reduction was implemented in clinical pathology labs payments. This was projected to save Medicare $2.7 billion over a decade. This reduction was directed under the Affordable Care Act (ACA). Moreover, there is also a possibility of another 2% reduction as part of federal budget-balancing efforts. By and large, it can be said that these actions could potentially result in a 23% reduction in clinical pathology lab facility fee cuts over a ten-year span. Amid all these fluctuating payment rates, it is getting hard for the healthcare provider to spend a substantial amount on a medical billing partner. Therefore, it can be said the payment reduction policy of a state poses serious threats to medical billing and coding practices concerning to the discipline of clinical pathology labs.

Molecular Clinical Pathology Lab CPT Code Modifications

Modifications in the CPT codes are also a concerning factor. For instance, CMS is considering the introduction of new codes to describe sub-molecular pathology tests and transferring some of these tests to the PFS. It is also a fact that Molecular pathology tests often require interpretation, which is typically performed by a Ph.D. geneticist. However, if the sub-molecular pathology test CPT codes shift from the CLFS to the PFS, a portion of the reimbursement will be transferred from the clinical pathology labs to the physician. This can occur even if the physicians are not involved in interpreting the test. So that is the problem here. According to a survey conducted by the American Clinical Laboratory Association (ACLA), approximately 80% of these services do not require physician interpretation. Similarly, there had been many other code modifications that seriously challenged the coders in submitting accurate claims by following all substantial guidelines effectively.

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