LabReflex

Hey everyone, welcome to LabReflex. I'm here with Dr. Aakash, how you doing man? I'm doing good, Chris, how are you? I'm doing fantastic. We are here late-ish summer now, early August. Yeah, and we are also revamping our lab slash studio. We have got some really good equipment now that we are excited to share someday with our listeners. Yeah, we have been building out our space. We have been working on the software tools, the pod studio tools. And so there've been a lot of changes on the backside. You all don't actually hear those changes, unfortunately, yet, but we're gonna be moving to video capable at some point in the near future. And to that end, we want to bling out our space here. I think the contribution that you made here to the neon lights is gonna be pretty awesome. I mean, it looks fantastic. So very much looking forward to it. Oh yeah, exactly. Well, in, I guess other news, we haven't missed a holiday since last week, which is fantastic. I do have my wife's birthday coming up and I think you have a special day coming up as well, of course. Yes, it's my wedding anniversary. Congratulations. Congratulations, man. Oh my gosh, that's fantastic. So looking forward to that. Yeah, so just for that too, I mean, there's an official one and then there's an unofficial one that me and my wife celebrate. So this is gonna be the unofficial one. Well, regardless, I hope you have a fantastic time. Thank you. And I mean, honestly, there's sort of two natural, for married people, obviously in the US, there's Valentine's Day and there's anniversary. And for me and my family, my mother was born on Valentine's Day. Okay, so it's a birthday for her too. Yeah, so unfortunately for my wife, she gets a little bit less of a celebration because like Valentine's Day is supposed to be about the woman in your life and then my mom, it's her birthday and what are you gonna do? So that it's always sort of a bit of a tweener as far as that kind of goes. Yeah, exactly, you kind of sort of torn there. So anyway, you on the other hand get two anniversaries, which is, I mean, I think fantastic. So you get three sort of relationship holidays for you and your wife. Anyway, so we kind of wanted to do a couple episodes this week, but first things first, we had a pretty big announcement from CAP this week. And I don't know if you all listeners saw the email, but we got an email from CAP concerning, I think a new change in the fee schedule for CMS or a proposed new changes to the fee schedule. And so we wanted to have kind of an emergency pod to talk about that because I think that there's a webinar coming up in the 12th, I think. And so we wanted to have a little bit of a taste ahead of time for that. Brief idea on what's going on and what would be discussed and we probably wanna like, we will be actually talking about post webinar, what came, what news comes from that also. Yeah, so the long and the short of it is, CMS is taking a look at a lot of CPT codes. And in particular, they're gonna be looking at pathology codes 88 through five and three or seven. And the reason for that look back is a study that was done in Maryland about their own billing. And that is, I think, interesting because the claim by Maryland is something like, there are so many providers, pathologists, who are billing so many 88 through five in a day that it's beyond the scope of how long it ought to take to do those 88 through five. So the standard is something like 25 minutes per 88 through five. And sometimes it was as short as two minutes to do one. Yeah, so basically what you're saying is like, the Maryland Health Care Commission, which is an independent state health policy and regulatory agency, basically they have come up with a, sort of a letter slash an argument stating that, they used claims database to identify CPT codes whose claim assigned physicians, time-produce implausible work days. Basically, they have a letter where they say that, the amount of 88 through five is being generated, that should be generated in a particular timeframe are being generated a little bit earlier or like in a faster maneuver. And they are concerned why is that so? And the way they are trying to calculate it is that, they say that the CMS qualifies as, when a pathologist generates an 88 through five, it is linked to a 25 minute work period. And what this commission is suggesting, is that it's not like that. The pathologists are generating way more, 83 or fives in terms of the amount of time in which time they are generating that, am I right? Yeah, no, that's exactly right. Yeah, so they took a look at their 2023 data and they linked the data by provider, date of service, code, and then number. And then literally just took that number and multiplied it by 25. And when they multiplied it by 25 minutes per, they found that there were some number of days where providers worked for more than eight hours in a day. And our numbers, it was something like 2,000 provider days. And there were a bunch of provider days that were actually more than 24 hours worked, 500 something days. So that's compelling on some level, because you say, holy cow, I mean, obviously it doesn't take you 25 minutes to do the work if you could do 24 hours of work or greater than 24 hours worth of work in a single day. Yeah. So it must have taken you less time. Therefore, it should take everyone some significant less amount of time, and therefore we should pay less for this analysis. Yeah, and the understanding is like why, to start understanding it would be like, why does Medicare assigns time to an 8305, right? So CVD 8305 is not billed in a 25 minute increment. A pathologist does not submit a claim saying that I spent a 25 minute time on my work. No, there's no claim against that, exactly. That's right, that's right. The CMS, behind the payments calculation, the CMS assigns each service an assumed amount of physician time. This assumed calculation time contributes to the physician work relative units or what we call as RVUs, right? For the 8305, the Medicare physician schedule currently carries an assumption that a 25 minutes of inter-service physician time is intended to represent the time when the physician is actively performing that service. Therefore, according to them, the dispute is not initially about an individual 380 three-year time claim was valid, that the physician actually spent it. It is about whether 25 minute valuation assumption remains realistic because they are saying that they are more 8305 than the time generated within the time than they should have been so they want to go back and reevaluate that number. Right, exactly. Yeah, there's this additional component that Maryland, so we should back up a little bit because where this information came from was a letter by Maryland sending to CMS. So the Maryland Healthcare Commission, I believe the person running it at the time was this guy, Dr. Douglas Jacobs, sent a letter to CMS with all of these claims. And in addition to those claims, there was a very small study done in 2016 by this Urban Institute. They did a pilot study looking at how long it took and how many CPT codes, specifically 8305s, could be charged or were being charged. And it was a very small study. I think something like three sites were studied there. And what they found was that it could take as little as two minutes to do an 8305. And that's not a terribly big surprise if you know anything about pathology sign-out. Sometimes you can get a lot of slides that take zero amount of time. I'm thinking of some of these pretty simple BCCs and SCCs for derm cases where there's not a lot of tissue, the biopsy is very small. And so that's not a terribly big surprise. And so then they took the intellectual jump from that point and compared the 25 minutes and the two minutes and said, look at this, we're overpaying by 12x, 13x. Which is, I mean, that's got to be considered disingenuous. I mean, there's no way that that's actually the conclusion that anyone who understands the workflow would make. Yeah, because see, it's just like saying that if I am looking at an 8305, right? And that 8305 took me, there were five cases of 8305 that took me, let's say 10 minutes each, maybe. Yeah, right. So I claim that 3, 5, 8305 within 25 minutes to 30 minutes extra time remaining on my bench, okay? But anybody who signs out the surgical pathology cases knows that not every 8305 takes five minutes, 10 minutes, or even to say 25 minutes, sometimes it takes more, right? And sometimes you might end up doing some extra efforts on that particular case. So does it really make sense to like say that, based on the number of 8305s that are being generated, physicians are not actually attending to that particular case and giving that much time? I don't know. Yeah, it's understandable that what you'd wanna do is aggregate the amount of time total, and then sort of divide by the total sign out. I think that's a logical conclusion, because what you wanna do is you recognize that if you're sitting at the scope and you sign out a case, that's not all the time that's attributed to that case, right, there's getting the cases, there's just getting into work, there's the reports, there's a bunch of things that you have to do. It's not just looking at the case and then making a determination. So it's understandable that they would try and really analyze the total cost and time. And on the other hand, like, I mean, 8305s to my understanding are the GI biopsies, et cetera, right? Yeah. So you are basically saying that a person who, over the time, got so good at, it is a skills that he can actually give you the results at an earlier rate now should be, Yeah. Should be made to, should not be paid enough for doing that. Right. Because in my assumption is that if you get better at something, you should be rewarded for it, right? Right, exactly. Yeah, the, what is, I think, interesting is that the numbers that we're talking about are all pretty small, right? We discussed how there's 1,763 provider days where the 8305 alone generated more than eight hours of CMS assigned intra-service, or intra-service time, intra-service time. And then among those, there was 587 days where the accumulated effort was greater than 24 hours. Okay. Assuming a 25 minute sign out time. But I mean, again, you might work a long day and you might have an unusually easy day where the cases are just flying. I mean, I remember I signed out with a dermatopathologist one time and we did something like 250 cases. Yeah. In a very short period of time. Exactly, but that's the thing, right? They might be hard for some one pathologist, they might be easier for the other pathologist, but at the pace that that other pathologist is signing out shouldn't be punished for him doing something faster because he knows, arguably he's doing it better or like he has more experience in doing it, right? Well, and the thing is, it's not even that person who's gonna be punished, right? The person who's gonna be punished is the person who takes longer. Yeah. So the person who's more contemplative, who thinks about it more deeply is the one who's gonna be punished the most because it's their billables that's gonna also be reduced. And the funny thing is that bill that was like, or the thing that we are talking about, they actually submitted it in an opposite way and then calculated the numbers from that. So Maryland temporarily assumed that CMS is 25 minutes figures correct and then asks why that assumption generates physical possible work days. If the answer is no, then they argued that the CMS time must be wrong, right? And then they had the screening threshold on how many provider days did one individual CPT code batch search generated in more than eight hours of assigned interservice time. Right, right. So they did not initially add every service that person built, that person built. Code first had to cross the eight hour threshold on its own. And from that they've identified 13 separate codes that were from muscular skeletal surgery, cardiovascular surgery, digestive surgery and surgical pathology to start with. And out of those 8.305 turned out to be the biggest outlier. Well, duh, of course, like between doing ethics and doing an 8.305, which one is gonna take lesser time? Right, right. And actually it's even more obvious. The report actually pointed out that it's not just pathologists that are using the 8.305 and billing more. Gastroenterology and dermatology are two other specialties that have illustrated a more than 24 hour number of reports, right? So that is perfectly consistent with our observation of the field. In both of those two specialties, what typically happens is a slide is prepared, easy cases are signed out by those clinicians. And then the hard stuff is sent over to the pathologist. So you could see a scenario where at a dermatology clinic, for example, a slide is prepared, all the easy stuff I sign out very quickly for my entire group, right? Maybe I'm a DermPath guy and I sign out those cases. And then the hard stuff I send over to my consulting pathologist because I don't wanna sign those out. So I could sign out a ton of cases really quickly because they're the easy ones. And then the hard stuff I totally turf. And so of course it's gonna take them less time. This is perfectly logical. If I'm doing all the easy stuff, right? It's like laundry at home, right? We have socks, you know, you have undergarments, you have shirts, and then you have towels. And towels are these enormous things. Take up a lot of space in the washing machine. And yet they're super easy to fold. I love folding the loads of towels. It takes me like three seconds. And I tell Michelle, listen, I folded an entire load of laundry and it took me like, you know, four articles of float. And that's exactly what this is, is the easy stuff that they're taken care of. And then they can sign out very quickly. And then they send off the hard stuff to someone else. And it's like, on the other note, then I would also like to find out that the cases of eight, eight, three, or five that took more. Yeah, exactly. Times and 25. Yeah, what about those? Exactly. What about those ones? Like that might have taken like maybe two hours. Right, right, exactly. I wanna see, if you are talking about the one extreme that cases that were under 25, I wanna see like, what was the other extreme where they took more time? And I wanna talk about them as well. Yeah, I think that it will be very interesting to see what CMS actually does with this data. Right now, what we don't know is that CMS is gonna propose something. Clinical fee schedule is gonna change in some meaningful way, but we don't know. They're not proposing that, you know, three or fives are two minutes worth of time. They're not proposing that it should drop by, you know, 12 X or anything like that. But we just simply do not currently know, you know. So now, I mean, we'll see what happens. We'll be waiting for August 12th, as they say and see what news do we have to. Yeah. What news comes out and what we can discuss on that part. But so far, I mean, this is what's going on. This is the one of the lingering topics that we got the news from Cap on this. You guys can go ahead and to all the listeners, you guys can go ahead on the Cap's website and read more about it. It's just explicitly stated over there. Do you have any comments on that? Yeah, I think the one thing that I've taken away from this whole episode is that we as a field need to start aggregating our own data. I think that the college should consider a database where we keep updated our billing, our coding and a bunch of other things that we use as a field to defend ourselves. The amount of information that Maryland was using to essentially attack the core of what we consider to be our billable code, the 8305, that is like bread and butter if there ever was a thing is so incredibly sparse. We're not talking about a ton of data here. And so the fact is that we as a field are defending ourselves against studies of like two or three different health sites. This like 2016 study is literally three sites. And we're talking about 2000, 3000 total work days that is an assault on the 8305. I think that that's a real misrepresentation of the data. And we don't have anything to combat it. And so if we started putting some of our own claims data and some of our own resulting data into some sort of central database, we'd be able to actually defend ourselves in a much more concerted way. I agree. I think that would be a good use of AI for coding. Yeah, exactly. And maybe, hey, you know what? Maybe LabReflex should be the site for that location. Maybe what we can do is you and I can build that. That'd be pretty trivial. And then we could start funneling a lot of that data and then we could defend ourselves. Yeah. We are open to that. Hey, let's do it. So anyway, with that, it was a great episode, man. I really appreciate it. I feel like I was complaining a lot this episode. I apologize to the listeners, but I think that I'm very excited about hearing what's going on on the 12th and we'll keep everybody posted. Sounds good. All right, thanks, man. Have a good one. Have a good one, everybody.