New economic forces require managers to examine existing protocols and develop methods to increase efficiency.
As economic forces pressure today's laboratory administrators, careful analysis of traditional practices in anatomic pathology become essential. These forces include increasing technical demands of the specialty, the reduction of doctors entering pathology residency programs, decreased money received from the government and third-party payers for pathology services, and the increasing surgical volume that has to be processed with current staff. As managers, we need to examine existing protocols and develop methods to increase efficiency of pathologists and laboratory personnel.
institute charge backs for producing information for researchers to recover technical and clerical time.
Laboratory managers are constantly inundated with Medicare updates; we also are watching Medicare reimbursement on selected professional components drop. Important to anatomic pathology last year was reimbursement for technical components that increased significantly in January 2000.
When reviewing the reimbursement changes for 2001, many of the drastic increases we saw in 2000 have been lowered for this year, such as 88313, 88314, 88342, 88346, 88348, 88108, 88173. The Table is a demonstration of technical component increases and professional component decreases in the Ohio/West Virginia Region. (Medicare reimbursement varies slightly by region.)
Professional reimbursement continues to drop on CPT codes 88300, 88302 and 88304. These are specimens submitted for gross only and smaller type specimens such as hernia sacs and gallbladders. Therefore, handling them as efficiently as possible is a necessity. Some of the specimens' pathology is medically insignificant to the patient's long-term care; therefore, managers and pathologists should review grossing practices to ensure their costs are below the Medicare reimbursement rates.
Grossing Protocols
Since laboratories are reimbursed by CPT code and not by the amount of blocks per code, reducing the blocks per specimen reduces cost per case. Our professional staff examined grossing protocols that had been standard for years. They determined sections that could be eliminated and not be detrimental or impact the quality of patient care we give.
Grossing protocols of larger surgical specimens (i.e., colon and uterus) in Level V (88307) and Level VI (88309) categories were examined to identify which sections were absolutely necessary for diagnosis. For example, lines of resection had always been submitted on colonic resections for carcinoma when the margins were grossly clear of tumor. Mucosal polyps and diveticuli when found in colon carcinomas had been submitted when not necessary for diagnosis, but for documentation purposes only. Eliminating these sections saved two to four blocks per case.
Two sections of cervix, anterior and posterior, had always been submitted on prolapse uterus to rule out dysplasia even though no additional medical treatment would be given to the patient. The decision was made to submit only one section of cervix, eliminating one block per case.
Also considered were Loop Electrosurgical Excision Procedure (LEEP) conization specimens (Level V CPT code) that were being marginated into 12 blocks. We receive approximately 500 LEEP conization cases per year. Submitting 12 blocks per case was equivalent to 6,000 blocks and slides, assuming deeper sections or recuts were unnecessary.
LEEP biopsies after sectioning are normally small segments of tissue that enable multiple pieces to fit into one cassette. Although small, each segment was submitted into its own specially designated cassette to determine dysplasia at the margin of resection. Through communication with the clinicians, we found there was no surgical follow-up if a margin was involved. The patients are followed more closely with PAPs when a margin is involved, so the exact margin designation became less significant.
We determined the specimen could be handled as efficiently placing four sections in one cassette and designating the margins by quadrants. Reducing the blocks submitted resulted in 4,000 less blocks and slides to produce, handle and store, resulting in a 200 percent decrease in blocks and slides per case.
Examining grossing protocol for Nodular Prostatic Hyperplasia specimens can make another dramatic block reduction. Debate exists on how much of a transurethral resection of the prostate (TUR, prostatic chip specimen) should be sampled to rule out coincidental carcinomas. These specimens are routinely received in most laboratories. Many laboratories submit the specimen in its entirety, possibly resulting in 30 or more blocks when coded as an 88305 regardless of the amount of blocks submitted. Laboratories submitting prostatic chips in total should consider the guidelines of Murphy et al,1 which are to begin by sampling 12 grams of prostatic chips. If carcinoma is encountered in this sampling, the remainder of the tissue is processed for staging.
Recommendations
CAP has published recommendations2 for institutions to determine which types of specimens should be submitted to pathology and specimens that may not require a microscopic evaluation. This brings up the question: How long will we continue to be reimbursed on specimens such as these? After CAP's recommendations are reviewed, the two options to consider are:
1. not submitting sections of selected specimens for microscopic evaluation or
2. not having selected specimens for "gross examination only" be submitted to pathology. The cost savings in labor may absorb additional specimen workload.
Evaluate specimens coded as 88302 Level II (i.e., bunions, hammertoes, pediatric tonsils and adenoids and torn meniscus) submitted for microscopic interpretation. Consider handling these specimens as Level Is (88300)—for gross examination only—following CAP recommendations to recognize a savings in labor, disposables and reagents. Although revenues may decrease slightly, the labor savings can be cost effective in reducing overtime costs as well as supporting an increased workload using the same amount of personnel. More importantly, surgical pathologists can be allowed additional time.
Also evaluate current specimens handled as gross onlys (Level I CPT Code 88300) to determine if it is medically necessary to submit these specimens to pathology. We evaluated more than 5,500 pathology reports that were by-products of cardiac bypass surgery (i.e., internal mammary artery pedicles, saphenous veins and sternal wires) and determined that they do not need to be submitted to pathology. Eliminating those being submitted for gross examination only recognized a costs savings in labor since they are never received in the laboratory. When evaluating costs, you will find revenues incrementally decrease at a lower rate than labor costs. Again, time saved in labor can absorb the additional specimen workload relatively.
When implementing this change, remember that CAP and the Joint Commission on Accreditation of Healthcare Organizations require the institution's reviewing board to approve all specimens not submitted to pathology and be in a written policy. Block reductions and eliminating selected specimen submissions into the laboratory reduced overtime and, more importantly, did not compromise quality patient care in any aspect in our facility.
Personnel
Pathologist assistants or pathologist extenders assisting pathologists in gross specimen dissection is another major savings of pathologists' time. The most expensive part of the entire laboratory operation is personnel; the most costly of persons is the surgical pathologist. Therefore, efforts that increase the productivity of surgical pathologists (i.e., increased numbers of surgical pathology reports per surgical pathologist) are economically desirable and can be accomplished by allowing non-pathologist personnel to perform gross dissection and description.
Although the gross description is often considered relatively unimportant, the need for the gross description and the time involved in performing the gross description and dissection cannot be overemphasized. Once a specimen has been totally submitted or discarded, the gross description is the only document by which gross features can be evaluated and the only place where confusion that may result from review of slides can then be resolved.
In many hospital laboratories, the gross specimens are described and dissected exclusively by fully trained surgical pathologists. This process takes a great deal of time, and experience has shown that this job can be done adequately and more cost effectively by persons who are less trained, but under the supervision of a surgical pathologist. Furthermore, various specimens received into the surgical pathology laboratory do not require a pathologist to see the gross tissue prior to interpreting the microscopic slide in the sign out room. In laboratories that receive a high volume of biopsies and dermatologic specimens, it may require one or more persons dedicated to describing and processing these specimens.
Some larger specimen types are well disposed to non-pathologist dissection such as colonic resections for carcinoma or axillary lymph node dissections. The handling of these larger specimens is usually consistent for each specimen type, with the same method of dissection, and sections submitted for light microscopy. Lymph node dissections are also time consuming and we have shown that technical personnel that do node dissections routinely yield a higher number of nodes found.
Many factors make a histotechnologist ideal for some aspects of gross specimen description and dissection, such as their familiarity with cutting, sectioning, processing and staining of tissue samples. They are usually conversant with varieties of surgical specimens and the types of tissues that might be received. They already know proper section size for adequate fixation, dehydration and penetration. Since histotechnologists are constantly in contact with surgical pathologists, they often exhibit a familiarity with medical terminology. Finally, in contrast to some pathologists or pathology assistants, histotechnologists can assist with some "grossing in" while continuing to perform other routine and special histotechniques. We have, therefore, created an expanded role for our existing technical staff.
Be aware, though, that federal regulations in CLIA '88 restrict educational requirements of the personnel who are performing human tissue examination.
The diener role for the autopsy suite, for example, was analyzed in our facility. We felt that the non-pathologist grossing personnel could be cross-trained in evisceration to eliminate the diener job classification. Our pathologist extenders were cross-trained in autopsy, which allowed us the savings of two full-time employees (FTEs), eliminating the diener job classification.
Technologies to Consider
Voice-activated transcription and outsourcing transcription is another major cost savings to consider. Voice-activated transcription systems have advanced dramatically in the last decade with multiple companies offering anatomic pathology programs. We purchased our first system in the early 1990s, recently upgrading to continuous speech.
We modified the gross descriptions on the voice-activated transcription system we purchased to match our programmed biopsy description, eliminating the need for transcription of biopsies and dermatological specimens at that time. The majority of these smaller type transcriptions can be formatted in a programmed transcription since they are very similar; only size and fixative may need to be dictated. Using the programmed descriptions on our voice-activated transcription system eliminated the need for one transcriptionist. With the upgrade to continuous speech, all specimens dictated by non-physicians are dictated using voice-activated transcription, eliminating additional transcription cost.
Another step in reducing transcription costs is investigating outside transcription agencies to eliminate onsite transcription FTEs and associated costs. We slowly integrated offsite transcription while continuing internal transcription by outsourcing autopsy gross description during the implementation, since turnaround time (TAT) of autopsy is not as crucial as surgical final diagnosis. Eventually, the majority of gross and final dictation has been outsourced, eliminating 4.8 FTEs.
Lastly, anatomic pathology departments store information such as slides, blocks and tumor statistics that have valuable information to researchers. We have had to institute charge backs for producing information for researchers to recover the technical and clerical time. Lower fees were developed for pulling blocks and slides, running searches and producing slides.
By careful evaluation of your current protocols and practices, many costs savings can be achieved.
Gwendolyn R. Goss is manager, Anatomic Pathology, Cleveland (OH) Clinic Foundation.
References
1. Murphy WM, Dean PJ, Brasfield JA, Tatum L. Incidental carcinoma of the prostate. How much sampling is adequate? Am J Surg Pathol 1986; 10:170-174.
2. Fitzgibbons P, Cleary K. Specimens for gross only. College of American Pahologists. CAP Today July 1996.