Pathology Lab Test Expert Witness qualifications and experience
Pathology Lab Test Expert Witness work in this specialty includes usual customary and reasonable cost of care, appropriate coding and billing based on industry best practices and guidelines, payor policies and medical specialties as well as specific patient populations. It may also include reviewing the test charge amounts versus national and regional charge averages, evaluating MUEs which are “Medically Unlikely Edits” as well as the cost of care based on national and regional rates. In states where the standard allows experts to provide opinions on net reimbursement rates, 50th, 75th, and 90th percentile data may be presented. Determining usual customary and reasonable costs for esoteric tests or any new area of medicine requires careful research to find data that represents the market rates in a specified A Core Based Statistical Area (CBSA). A CBSA is a U.S. geographic area defined by the Office of Management and Budget (OMB) that consists of one or more counties (or equivalents) anchored by an urban center of at least 10,000 people plus adjacent counties that are socioeconomically tied to the urban center by commuting.. Identification of providers who perform the tests in a similar time frame and setting may also be relevant. Also, national correct coding initiative algorithms may be used to evaluate the tests versus national coverage determination and local coverage determination policies.
See also our expert witness services for esoteric tests.
Experience includes
- Pathology for Nephrology patients
- Pathology for dialysis patients
- CPT codes, CPT code most appropriate for medical service
- National Correct Coding (NCCI) standards and edits
I. Retained by Defense in case of Plaintiff v. Leading Academic Medical Center and Pathology Group
Provide expert rebuttal opinion regarding molecular diagnostic pathology laboratory coding and billing and best practices in 31 U.S.C. § 3729. (a) False Claims Act; opinions based in part on NCCI (National Correct Coding Initiative), and industry best practices and guidelines regarding CPT coding for pathology, diagnostics, clinical dosages, and physician supervision and Medicare Part C reimbursement under risk adjustment Evaluation of use of combination of codes including:
- CPT 87491 infectious agent detection by nucleic acid (DNA or RNA); Chlamydia trachomatis, amplified probe technique
- CPT 87623 Infectious agent detection by nucleic acid (DNA or RNA); Human Papillomavirus (HPV), low-risk types (e.g., 6, 11, 42, 43, 44),
- CPT 87624 Infectious agent detection by nucleic acid (DNA or RNA); Human Papillomavirus (HPV), high-risk types (e.g., 16, 18, 31, 33, 35, 39, 45, 51, 52, 56, 58, 59, 68),
- CPT 87625 Infectious agent detection by nucleic acid (DNA or RNA); Human Papillomavirus (HPV), types 16 and 18 only, includes type 45, if performed;
- Modifiers including 91 (repeat clinical diagnostic laboratory test is used to report the same lab test when performed on the same patient, on the same day, to obtain subsequent test results) and 59 (when reporting lab procedures, modifier 59 is used when the same lab procedure is done, but different specimens are obtained, or the cultures are obtained from different sites).
II. Retained by Plaintiff in Kidney Medical Group v Medical Management Group
Evaluate business, medical documentation, coding and claims reimbursement practices of a Nephrology business which offers diagnostic and interventional procedures related to patients’ dialysis access needs.
- Opinions based on all-inclusive fees for risk-adjusted patients with End Stage Renal Disease (“ESRD”)
- Medicare Part C reimbursement under risk adjustment scenarios including “Medicare composite rate,”
- Routine pathology tests associated with ESRD patients, non-routine ‘send out’ tests,
- Compliance with 42 CFR Part 422 – Medicare Advantage Program, 42 CFR §422
- ESRD Prospective Payment System (ESRD PPS) – Section 153(b) of Pub. L. 110- 275,
- Medicare Improvements for Patients and Providers Act of 2008 (MIPPA) amended section 1881(b) of the Social Security Act to require the implementation of an ESRD bundled payment system and updates from 2004
- Updates through 2015.
- Evaluate potential issues with double billing / fraud.
Selected Lab and Pathology Testing Opinions
Usual, Customary and Reasonable costs in regional markets or national fees, National Correct Coding Initiative edits on medical necessity according to payor policiesTest Description | CPT |
---|---|
Albumin | 82040 |
Alkaline Phosphate | 84075 |
AST/SGOT | 84450 |
Blood Urea Nitrogen | 84520 |
Calcium | 82310 |
Carbon Dioxide | 82374 |
Chloride | 82435 |
Complate Blood Count (platelet) | 85027 |
Complete Blood Count (CBC) | 85025 |
Creatinine | 82565 |
Hematocrit | 85014 |
Hemoglobin | 85018 |
LDH | 83615 |
Magnesium | 83735 |
Phosphorus | 84100 |
Potassium | 84132 |
Protime | 85610 |
PTT | 85730 |
ALT/SGPT | 84460 |
Aluminum | 82108 |
Anti HCV | 86803 |
B Type Natruiretic Peptide | 83880 |
Basic Metabolic Panel | 80048 |
Bilirubin Direct | 82248 |
Bilirubin Total | 82247 |
Cholesterol | 82465 |
CK-CPK (Creatinine Kinase) | 82550 |
Creatinine Clearance | 82575 |
Creatinine Urine (24 hr) | 82570 |
Creatinine Urine (random) | 82570 |
Digoxin | 80162 |
Electrolyte Panel | 80051 |
Erythrocyte Sedimentation Rate | 85651 |
Ferritin | 82728 |
Folate (Folic Acid) | 82746 |
GOT | 82977 |
Glucose | 82947 |
Hemoglobin A 1c | 83036 |
Hemoglobin A le w/ MBG (eAG) | 83036 |
Hepatic Function Panel | 80076 |
Hepatitis B Antibody (HBsAb Quan) | 86317 |
Hepatitis B Antigen (HBs AG) | 87340 |
High Density Lipoprotein | 83718 |
Highly Sensitive C Reactive Protein | 86141 |
Homocysteine | 83090 |
Iron | 83540 |
Lipid Panel | 80061 |
Microalbumin (24 hr) | 82043 |
Microalbumin (random urine) | 82043 |
Occult Blood | 82270 |
Parathyroid Hormone | 83970 |
Prealbumin | 84134 |
Protein Total | 84155 |
PSA | 1013 |
PSA Total | 84154 |
Reticulocyte Count | 85045 |
Sodium | 84295 |
Thyroid Stimulating Hormone | 84443 |
Total Iron Binding Capacity (TIBC) | 83550 |
Total Protein Urine ( 24 hrs) | 84156 |
Total Protein Urine (random) | 84156 |
Total Protein/Creatinine Ratio | 86141 |
Total T4 | 84436 |
Triglycerides | 84478 |
UIBC | 83550 |
Uric Acid | 84550 |
Vancomycin | 80202 |
Vitamin Bl 2 | 82607 |
Alfa Fetaprotein | 82105 |
Amikacin | 80150 |
Ammonia | 82140 |
Amylase | 82150 |
ANA w/ reflex to titer | 86038 |
ANCA | 86021 |
Blood Culture | 87040 |
Blood Type (ABO) | 86900 |
Blood Type (Rh) | 86901 |
C. Difficile Toxin | 87230 |
CA 125 | 86304 |
Calcium Ionized | 82330 |
Carnitine | 82379 |
CEA | 82378 |
CK-MB | 82553 |
Complement 3 (C3) | 86160 |
Complement 4 (C4) | 86162 |
C-Peptide | 84681 |
CPK | 84681 |
Creatine Kinase Isoenzymes | 82552 |
Cyclosporine | 80158 |
Dilantin | 80185 |
Drug Screen (serum) | 80101 |
Drug Screen (serum) confirm | 80100 |
Erythropoeitin | 82668 |
Estradiol | 82670 |
Estriol | 82677 |
Free T3 | 84481 |
Free T4 | 84439 |
FSH | 83001 |
Gentamycin | 80170 |
Giardia Antigen | 87329 |
Gram Stain | 87205 |
Hepatitis B Core IgM Antibody | 86705 |
Hepatitis B Core Total | 86704 |
Hepatitis C RNA by PCR (qual) | 87521 |
Hepatitis C RNA by PCR (quan) | 87522 |
Hepatitis C w/ RIBA | 86803 |
HIV Screening | 86701 |
lmmunofixation, serum | 86334 |
LH | 83002 |
Lipase | 83690 |
Methylmelonic Acid | 83921 |
Myoglobulin | 83874 |
Ova & Parasites (O&P) | 87177 |
PD Fluid Cell Count | 89051 |
Progesterone | 84144 |
Prolactin | 84146 |
PSA Free | 84153 |
Renin Activity (plasma) | 84244 |
Rheumatoid Factor | 86431 |
SHBG | 84270 |
SPEP | 84165 |
Sputum Culture | 87070 |
Stool Culture | 87045 |
Swab Culture | 87075 |
T3 Uptake | 84479 |
Tacrolimus | 80197 |
Testosterone Free | 84403 |
Testosterone Total | 84403 |
Total T3 | 84480 |
UPEP (24 hr) | 82570 |
UPEP (random) | 84156 |
Urinalysis | 81001 |
Urinalysis Complete w/ reflex to culture | 81001 |
Urinalysis Complete w/ reflex to micro | 81003 |
Urine C&S | 87086 |
Valporic Acid | 80164 |
Vitamin A (retinal) | 84590 |
Vitamin B 1 (thyamin) | 84425 |
Vitamin B2 (riboflavin) | 84252 |
Vitamin B6 (pyridoxine) | 84207 |
Vitamin C | 82180 |
Vitamin D 25 Hydroxy | 82307 |
Vitamin D Di-hydroxy | 82652 |
Vitamin E (tocopherol) | 84446 |