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.

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