By Christopher P. Young, Editor, G2 Compliance Advisor
The Centers for Medicare and Medicaid Services (CMS) has removed the national coverage determination (NCD) for electron microscopy (EM) from the Medicare National Coverage Determinations Internet only manual (Pub 100-03), leaving coverage determinations to the local Medicare Administrative Contractors (MACs). According to transmittal R180NCD, the effective date for the change is Dec. 18, 2014 and the implementation date is April 6, 2015.
The EM NCD, along with six other non-laboratory determinations, was removed according to an expedited process for removing NCDs meeting certain criteria, described in a Aug. 7, 2013 Federal Register notice. Basically, the process calls for review of NCDs that have not been reviewed in 10 years or more, have been replaced by newer technology or are no longer being used by many providers. The selected procedure is posted for public comment for 30 days. The objective is to evaluate the need for the policy to remain active at the national level. This leaves the door open to the local MAC to make a coverage determination based on its own concept of the medical usefulness of the test.
EM is used for examinations of biopsies and is paid under the physician fee schedule. Its technical component pays about 3.5 times higher than the professional component. EM (Current Procedural Terminology code 88348) has been covered by Medicare for years and its efficacy is not in question. However, according to the current coverage policy, there are less expensive methods for examining biopsies that are normally adequate. The NCD goes on to say that, “The additional expense for the electron microscope is normally warranted only when distinguishing different types of nephritis from renal needle biopsies or when there is an uncertain diagnosis from the pathologist.” It also says that in the case of uncertain diagnosis by a less expensive procedure necessitating the electron microscopy, both procedures are covered. In this case, if the EM exam is not warranted, only the procedure with the lowest cost will be reimbursed.
According to CMS claims data for 2012, obtained from the CMS national claims data released in April 2014, a total of 252 facility and non-facility providers performed the service 12,032 times. CMS received no comments from the public on this procedure.
Laboratories that perform this procedure should watch for their local MAC to publish information about coverage for electron microscopy procedures and review their claims for denials of this procedure after the new policy becomes effective. Compliance officers may want to review their facilities’ use of this code to determine how often EM procedures are performed on the same patient on the same day as another tissue exam. In that case, the report on the tissue exam should note the need for the EM procedure.