New CPT for H. pylori Test Signals Higher Volumes

CMS has assigned a new CPT code (86318QW) for 31 quick, low-cost immunoassay blood tests for Helicobacter pylori.  But, unless you have had an ulcer or are in the GI field, you may not know what Helicobacter pylori (H. pylori) is.  H. pylori is a bacteria that in the 1980s was found to cause 90% of all peptic ulcers.  With ulcers costing hospitals $3 billion a year to treat, coverage for H. pylori tests could save a significant amount.

Currently, there are multiple tests for diagnosing H. pylori, ranging form antibody tests run on blood, urine, or stool samples to obtaining a biopsy sample.  The most recent is C13/C14 urea breath test.  Clinical trials have revealed that immunoassay blood tests have 96% sensitivity and 79% specificity.  In comparison, 13C breath tests have 95% sensitivity and 86% specificity.

One primary advantage of a breath-based technology, besides a slightly higher specificity, is it is a very convenient test to administer; the drawback is it is a $90 to $120 test.  On the other hand, immunoassay technology has been around for years, so new tests can be added with software upgrades and a test cartridge, allowing for the technology to process most tests in the $10 to $20 range.

I spoke to Dr. Paul J. Jannetto, PhD, MT (ASCP), assistant professor of Pathology, assistant director of Clinical Chemistry/Toxicology, and director of Rapid Response Lab, Department of Pathology at the Medical College of Wisconsin in Milwaukee, WI, about costs and utilization.  Dr. Jammetto said, “Everybody has to be cost conscious now.  The costs of some tests are so high that physicians are not ordering them.  Because of this, they may wait for more advanced clinical signs to appear.  This is a primary reason why not all tests have advanced as quickly as they could have.”

The immunoassay blood test for Helicobacter pylori (86318QW) is currently being reimbursed at approximately $20, which is considerably less than the $96 (830012) for a breath-based test.  But, with healthcare’s focus on cost control, more tests will be prescribed at the early stages of the disease.  This should assist providers in prescribing a treatment for a patient before an ulcer starts to bleed or worse, develops into cancer.

When you think about it, it’s an interesting concept.  Lower reimbursement and improved outcomes should lead the other way.  Let’s follow this and see how the numbers turn out.

James Laskaris, EE, BME
James Laskaris, EE, BME, Clinical Analyst — Mr. James Laskaris is a senior emerging technology analyst at MD Buyline and has been with the company since 1994. With over 30 years of experience in the healthcare field, Mr. Laskaris is the primary analyst of high-end OR technology. He also covers issues related to the legislative and reimbursement effect on healthcare and authors a bimonthly “Issues that Matter” publication. Mr. Laskaris received his biomedical engineering degree from Southern Illinois University. His work has been published in hfm Magazine, Radiology Manager and Healthcare Purchasing News.