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.

Pathology Lab Test Expert Witness
Michael Arrigo expert witness in Federal State and Civil Courts on ACA, HIPAA, Healthcare costs in malpractice and personal injury, False Claims Act cases involving Medicare Advantage and Electronic Health Records

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:

  1. CPT 87491 infectious agent detection by nucleic acid (DNA or RNA); Chlamydia trachomatis, amplified probe technique
  2. CPT 87623 Infectious agent detection by nucleic acid (DNA or RNA); Human Papillomavirus (HPV), low-risk types (e.g., 6, 11, 42, 43, 44),
  3. 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),
  4. CPT 87625 Infectious agent detection by nucleic acid (DNA or RNA); Human Papillomavirus (HPV), types 16 and 18 only, includes type 45, if performed;
  5. 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 policies
Test DescriptionCPT
Albumin82040
Alkaline Phosphate84075
AST/SGOT84450
Blood Urea Nitrogen84520
Calcium82310
Carbon Dioxide82374
Chloride82435
Complate Blood Count (platelet)85027
Complete Blood Count (CBC)85025
Creatinine82565
Hematocrit85014
Hemoglobin85018
LDH83615
Magnesium83735
Phosphorus84100
Potassium84132
Protime85610
PTT85730
ALT/SGPT84460
Aluminum82108
Anti HCV86803
B Type Natruiretic Peptide83880
Basic Metabolic Panel80048
Bilirubin Direct82248
Bilirubin Total82247
Cholesterol82465
CK-CPK (Creatinine Kinase)82550
Creatinine Clearance82575
Creatinine Urine (24 hr)82570
Creatinine Urine (random)82570
Digoxin80162
Electrolyte Panel80051
Erythrocyte Sedimentation Rate85651
Ferritin82728
Folate (Folic Acid)82746
GOT82977
Glucose82947
Hemoglobin A 1c83036
Hemoglobin A le w/ MBG (eAG)83036
Hepatic Function Panel80076
Hepatitis B Antibody (HBsAb Quan)86317
Hepatitis B Antigen (HBs AG)87340
High Density Lipoprotein83718
Highly Sensitive C Reactive Protein86141
Homocysteine83090
Iron83540
Lipid Panel80061
Microalbumin (24 hr)82043
Microalbumin (random urine)82043
Occult Blood82270
Parathyroid Hormone83970
Prealbumin84134
Protein Total84155
PSA1013
PSA Total84154
Reticulocyte Count85045
Sodium84295
Thyroid Stimulating Hormone84443
Total Iron Binding Capacity (TIBC)83550
Total Protein Urine ( 24 hrs)84156
Total Protein Urine (random)84156
Total Protein/Creatinine Ratio86141
Total T484436
Triglycerides84478
UIBC83550
Uric Acid84550
Vancomycin80202
Vitamin Bl 282607
Alfa Fetaprotein82105
Amikacin80150
Ammonia82140
Amylase82150
ANA w/ reflex to titer86038
ANCA86021
Blood Culture87040
Blood Type (ABO)86900
Blood Type (Rh)86901
C. Difficile Toxin87230
CA 12586304
Calcium Ionized82330
Carnitine82379
CEA82378
CK-MB82553
Complement 3 (C3)86160
Complement 4 (C4)86162
C-Peptide84681
CPK84681
Creatine Kinase Isoenzymes82552
Cyclosporine80158
Dilantin80185
Drug Screen (serum)80101
Drug Screen (serum) confirm80100
Erythropoeitin82668
Estradiol82670
Estriol82677
Free T384481
Free T484439
FSH83001
Gentamycin80170
Giardia Antigen87329
Gram Stain87205
Hepatitis B Core IgM Antibody86705
Hepatitis B Core Total86704
Hepatitis C RNA by PCR (qual)87521
Hepatitis C RNA by PCR (quan)87522
Hepatitis C w/ RIBA86803
HIV Screening86701
lmmunofixation, serum86334
LH83002
Lipase83690
Methylmelonic Acid83921
Myoglobulin83874
Ova & Parasites (O&P)87177
PD Fluid Cell Count89051
Progesterone84144
Prolactin84146
PSA Free84153
Renin Activity (plasma)84244
Rheumatoid Factor86431
SHBG84270
SPEP84165
Sputum Culture87070
Stool Culture87045
Swab Culture87075
T3 Uptake84479
Tacrolimus80197
Testosterone Free84403
Testosterone Total84403
Total T384480
UPEP (24 hr)82570
UPEP (random)84156
Urinalysis81001
Urinalysis Complete w/ reflex to culture81001
Urinalysis Complete w/ reflex to micro81003
Urine C&S87086
Valporic Acid80164
Vitamin A (retinal)84590
Vitamin B 1 (thyamin)84425
Vitamin B2 (riboflavin)84252
Vitamin B6 (pyridoxine)84207
Vitamin C82180
Vitamin D 25 Hydroxy82307
Vitamin D Di-hydroxy82652
Vitamin E (tocopherol)84446