2015-06-23 12:51:24 UTC

New Coverage Determinations on Special Stains for GI Endoscopy

June 23, 2015

Additional Medicare Administrative Contractors have defined new standards for certain stains.

Three Medicare Administrative Contractors (MACs) have issued draft local coverage decisions on special stains and immunohistochemical (IHC) stains for GI endoscopy specimens identical to the LCD Palmetto GBA* finalized last year. Following Palmetto’s lead, the First Coast Service Options*, Noridian* and CGS Administrators* draft LCDs define the standards by which GI endoscopy specimens should be evaluated using special stains and immunostains, which are performed and billed by pathologists. 

The LCDs state:

“Ordering special stains or IHC stains prior to review of the routine H&E stain is not reasonable and necessary. For most esophageal, gastric and duodenal specimens, it is not reasonable or necessary to perform special stains such as alcian blue — periodic acid Schiff (AB-PAS) or other mucin stains, such as diastase — PAS (D-PAS), or IHC stains, such CDX-2, to determine if clinically meaningful intestinal metaplasia is present. In addition, it is not usually reasonable and necessary to perform special stains or IHC to determine the presence of H. pylori organisms.”

Other examples not considered reasonable and necessary on every specimen include:

  • Esophagus — fungal stains, trichrome, DPAS, CDX-2 or other mucin stains
  • Gastric — AB-PAS, D-PAS, CDX-2 or other mucin stains, or special stains or IHC for H. pylori, or neuroendocrine markers, such as synaptophysin or chromogranin
  • Duodenum — AB-PAS, D-PAS, CD3 and trichrome, or other mucin stains
  • Colon — CD3, p53 trichrome
  • Hyperplastic polyps — Ki67, CK20, p53, CEA, BRAF
  • Tubular or tubulovillous adenoma — Ki-67, CK20, CEA, p53, MMR

*Click accept to see the individual MAC coverage determinations on cms.gov.

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