- Familial History
Familial History Diagnoses Are Taking A Hit
LCDs are almost completely identical between Cahaba and Palmetto.
However, the one difference (and a drastic difference at that), is Palmetto includes a much broader spectrum of diagnoses.
This means that the molecular diagnostic field is highly impacted by the wide range of new diagnosis possibilities.
Familial History Diagnoses (FHDx) pertain to most tests run on situations regarding hereditary risks with health issues.
For example, say you have a family history of breast cancer. You go to the doctor for a biopsy on a tissue sample, and the BRCA test ran because of that familial history.
These are proving much difficult to get paid than tests run on individuals already having the personal diagnosis.
Claim Recoupment Crusades By Palmetto
In addition to familial history crackdown, Palmetto is crusading to review all payments by Cahaba for potential recoupments.
All previous payments made by Cahaba that are reviewable are now under scrutiny by the new MCR contractor.
This means your lab could face potential recoupments of payment by Palmetto.
Be on the lookout for this processing trend in Jurisdiction M and J.
Z-Code Trends Further Complicate Billing Process
Z-Codes are now here to impede proper reimbursement.
- Standardizing code classification which means a Z code will now specify the gene potentially decreasing reimbursement
Many experts, including us at Apache Health, hypothesize that Palmetto won the contract because they are extensively more financially stringent than Cahaba.
In line with this, the shift will likely include recoupment reviews on previous payments and further reimbursement complications.
A major trend we see happening is that Palmetto will continue its crackdown on Familial History CGx and move next to PGx.
Familiarize yourself with Z-Codes and their processing requirements to better prepare your lab for their enforcement in July.
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