By Frederick Kiechle
10/09/07

Provider-Performed Microscopy

Frederick L. Kiechle, M.D., Ph.D.

The federal law described by Center for Medicare and Medicaid Services (CMS) in the Clinical Laboratory Improvement Amendments of 1988 (CLIA ’88) classify laboratory procedures based on their complexity using well-defined criteria: waived, moderately complex, highly complex, and provider-performed microscopy.(1) Provider-performed microscopy, as defined by CLIA ’88, is a subset of tests classified as moderately complex that are performed by a practitioner. Only the bright-field or phase-contrast microscope can be used. Polarized microscopy of synovial fluid for crystals is excluded.(2) The specimens are labile or delay in performing the test could compromise the accuracy of the test result. Quality assurance is difficult since these microscopic evaluations have no control materials available.(3,4)

Table 1 describes the CPT codes for these microscopic evaluations(5) originally defined in the Federal Register of April 25, 1995, and revised on October 1, 1998. Interpretation of the microscopic examination of KOH preparations may be billed as Q0112 (Table 1) for nonpathologists or 87220-26 for pathologists.(3) The three-glass test (CPT code 81020, Table 1) of Meares and Stamey is used to evaluate the pathogenic site of urinary tract problems in males. The urine is collected sequentially in three containers, and each container is examined microscopically. Abnormal findings suggest different anatomic location of infection: first tube, uretheral problem; second tube, bladder or upper urinary tract; third tube, prostatitis. The clinical utility of the modified two-glass test has been questioned.(4)

How to manage the physician-performing provider-performed microscopy? This activity could be placed on the central laboratory’s CLIA license. I would not recommend this course of action, since the absence of QC and lability of the samples makes quality monitoring impossible. I prefer to have a designated practicing physician in the clinical area obtain a provider-performed microscopy license from CLIA. This license will also allow the physician and his/her designees to perform waived testing if they so choose. Typically in a hospital setting, the waived testing service is left to the laboratory-directed point-of-care testing program, usually under the central laboratory CLIA license. Data from CMS indicate that waiver license numbers increased from 67,294 in 1993 to 117,418 in 2006 while provider-performed microscopy licenses increased from 16,443 to 38,814 in the same time interval. Provider-performed microscopy provides unique revenue cycle and oversight challenges for the medical director of clinical pathology.

References

1. Ehrmeyer SS, Loessig RH. Regulatory requirements (CLIA ’88, JCAHO, CAP) for decentralized testing. Am J Clin Pathol 1995; 104 (Suppl 1): S40-S49.
2. Provider-performed microscopy testing; Approved Guideline. Clinical and Laboratory Standards Institute Document H52-A. CLSI: Wayne, PA; 2003.
3. Kiechle FL, Gauss I. Provider-performed microscopy. Clin Lab Med 2001; 21:375-387.
4. Kiechle FL, Gauss I, Robinson-Dunn B. Provider-performed microscopy. A review. Point of Care 2003; 2:20-32.
5. Current Procedural Terminology CPT 2007, Professional Edition. American Medical Association: Chicago, IL 2006

Table 1

Provider-performed microscopy procedures