The New Jersey Society of Pathologists

Welcome colleagues! I am excited to celebrate this milestone event with all of you!

I joined the New Jersey Society of Pathologists when I returned to New Jersey to complete my residency in 2005. At that time, I was interested in the society mostly from an education standpoint, as we had famous pathologists speak at our meetings. Once I became an attending post-fellowship, I became more keenly aware of not just the educational benefits of being a member of the NJSP, but of the important advocacy work that is done on behalf of all pathologists in the state of New Jersey. In 2012 I had the pleasure of becoming one of the first co-chairs of the Young Pahtologists’ Section, working with the Executive Committee to establish the statewide residents’ poster session, as well as developing the Society’s Social Media presence. Today I am honored to serve as your Vice-President. I am grateful for the opportunities for growth and leadership within the NJSP as well as the opportunity to connect with colleagues and friends all over the state and continue to work on behalf of pathologists in the great state of New Jersey!

Over the past 60 years, members of our society witnessed the transformation of medicine and our specialty. We have seen techniques such as immunohistochemistry, flow cytometry and FISH revolutionize Pathology practice. The NJSP and other Pathology organizations have navigated our members through numerous federal and state laws and regulations including Medicare, Medicaid and CLIA.

Our current climate of change and uncertainty is not something new; we have been there before. Molecular Pathology is now well established in routine practice. Developments in information technology allow high resolution digital images to be transmitted and reviewed in real-time. Future artificial intelligence tools will offer opportunities to achieve greater diagnostic accuracy and efficiency.

Pathologists will continue to transform our practice of medicine to improve patient care and expand access to all patients. The NJSP plays an important role by offering educational opportunities and advocating for our members and the patients we serve.

It was a great privilege to serve as President of New Jersey Society of Pathologists. When I became President, NJSP was already a strong organization serving the professional and educational interests of pathologists in our state. Our Society, along with our partners at the CAP and our legal and lobbying team, worked hard to address the evolving needs of our members. For example, during my time as President, we were able to secure the ability of hospital-based pathologists to serve their clinical colleagues when specimens are obtained outside the hospital. Our Educational committed increased the participation and role of residents at NJSP, helping to identify leaders for our future (with all credit due to Drs. Goldfischer and Fyfe for this accomplishment). We also began working with legislators to address “surprise billing” in a way that is fair to our membership. I am grateful for those who worked with me to make NJSP a success. Thank you for the opportunity.

I served as President from 2011-2013, which is either a decade ago or yesterday. I had the good fortune to serve on the executive committee, after being nominated by Dr Joseph Lombardo, who at the time was the Chair of our Department and Past President. I then replaced Dr Mario Gonzales as education committee chair, planning our Fall and Spring meetings. My decision to serve as President of the NJSP, as was the tradition back then, was not made by me, but for me by Dr Leschhorn. You see, one did not necessary campaign or even volunteer to serve an officer, you were nominated by your peers. I have tried, with limited success, to continue that tradition, but now thanks to LJ we are more diplomatic, democratic, and less intimidating. Serving as President was a fantastic experience and honor. I was given the opportunity to work with Laurie Clark to meet State Senators, Congressmen, Assemblymen and Women, attend social events, and even make donations to try to further our agenda. I worked with John Fanburg to try to limit the scope of proposed Out of Network Legislation. I worked with the CAP and Barry Zyman to fight for the rights of individual practices while working collectively for a common goal. I learned, I lobbied, I labored, I laughed, and through it all, Linda Bartolo, was there, my right-hand woman and she is dearly missed.

I enjoyed the comradery we shared as member of the executive committee, fighting for our independence and to have a voice as a small specialty in a state where the private insurers seemed to have all the influence. I made long lasting friendships, saw friends and colleagues nominated to the executive committee, many of whom went on to serve as President. Of the accomplishments that I am most proud of are in each of the 3 areas the society focuses on: In education, I made sure that molecular pathology was included in each Fall Slide seminar. On the legislative front, working to help complete the work started by Dr Z in fighting to have the Genetic Counselor law repealed stands out. If we had not been successful in this legislative effort, we all would be breaking the law daily. In the administrative realm, I believe I was responsible for inviting the 3 New Jersey Resident Program Directors, Drs. Dardik, Fitzhugh and Fyfe to attend the executive committee meetings and elect a resident representative.

As I look back, I remember at one executive committee meeting a disagreement with one of the senior members of regarding my suggestion of raising the exhibitor fees for the Fall Seminar. It reached a point where I was informed that, “You should know, this society was formed while you were still in diapers.” The New Jersey Society of Pathologists is celebrating its 60th year, which means this society was formed 3 years before I was born to be exact. However, now I am the most senior member in attendance with the longest tenure on the executive committee, a position I enjoy. I know I have benefitted from my affiliation with the society and hope I have been an asset as well. Our next President is a former resident I helped train. Our Current President I invited to join the executive committee.

I would encourage all who are interested to get involved, join the society, the executive committee, run for or be appointed officer, or even President. While many state societies have ceased to exist due to lack of membership, interest, or funds, to still be active as a state society today, is no small accomplishment. After 60 years strong, the NJSP needs your involvement and continued commitment to remain strong for the next 60 years together.

I was Vice President of the Society for 2 years then President for 2 more years following the presidency of Jonathan Lara (deceased) from St. Barnabas whom I greatly respected. I was not a founder of the Society.

During my tenure we decided that NJSP needed its own lobbyist and worked with the CAP who agreed to share that cost. We hired Laurie Clark, who turned out to be extremely valuable and effective representing our interests to the State.

We worked with Laurie to affirm standards of practice as when we were challenged by the Genetic Counselors society who wished to exclude physicians from their interaction with patients. We won this argument by presenting our case to the State Legislature. Physicians must be legally included in this interaction to provide appropriate and relevant interpretation of genetic testing. Although NJSP “carried the ball” on this case, MSNJ fully supported this outcome.

We ”discovered” with the help of John Fanburg that there existed a legal requirement for the New Jersey Board of Medical Examiners to have one member designated as a “biomedical laboratory director” and that position was vacant. This did not have to be an MD – but obviously we wanted to be sure it was a pathologist. We were able to successfully nominate Elliot Krauss to fill that position for two years. I currently occupy that role.

We spent a lot of time discussing economic issues since at that time most pathologists were separately billing for prof component AP and generally receiving Part A payments. There was much discussion about the practice of splitting pathologists’ professional component with gastroenterologists etc. This was also an ongoing topic of discussion at national CAP meetings. There was no resolution of this issue. Now, for better or worse, various salaried arrangements are the norm.

All of our NJSP meetings, which included great educational seminars and professional practice updates were very well attended and successful.

Warmest regards,

Louis Zinterhofer MD

As my term comes to an end, I cannot but think about the forces affecting pathology throughout the country. Our professional life has gotten more difficult the last two years I have been in office. We have experienced loss of volume and revenue to market forces that have been unstoppable so far. To add to the equation, Pathology keeps rapidly evolving; molecular pathology, proteomics, pharmacogenomics, targeted therapy, etc, are terms we read every day, which testing is getting simpler and cheaper and which clinicians will doubtless try to take ownership of. What do we do? We must learn and adapt. Below are some points I want to share with you in my final report.

Contractual Joint Ventures: In-office AP laboratories and TC/PC split continue to expand, with many “turn-key” companies and laboratories participating in both models. The final CMS 2009 anti-markup provisions allowed clinicians groups, through heavy lobbying, to continue these practices, which all pathology organizations hoped would cease. The CAP has placed CJVs in the back burner for now, although it intends to further pursue it with CMS alleging that in-office AP laboratories are purely revenue driven and do not fulfill the true intent of the in-office ancillary services exception.

Transformation of Pathology: On the other hand, the CAP has fully dedicated itself to the “Transformation” of pathology, along the creation of the “Institute for the Advancement of the Pathology Specialty”. Its leadership believes we must develop a more proactive role in directing patient care, including therapeutic options. They believe it will be a matter of time before we are relegated to be “glorified technologists” if we don’t change our role and perception people have about us. We must be visible, talk to the patients, explain what laboratory or pathology results mean to them, what options they may have and direct their care. The CAP is looking for pathologists exemplary for this role, such as our own Miguel Sánchez, from Englewood Hospital, who has been instrumental in developing its successful breast center. Miguel has been an active instructor in the Ultrasound Guided Fine Needle Aspiration (USFNA) Certificate Program of the CAP.

A large number of pathologists are skeptical about the success of this “Transformation” move, but I am afraid to find out the consequences if we don’t embrace it, especially when major changes are reshaping the delivery of healthcare in the nation. What will our role be in the future?

Direct Billing: Although New Jersey has had Direct Billing laws for many years, which prohibit clinicians from marking up purchased laboratory tests, some laboratories still offer such markup in the TC component of anatomic pathology tests on patients with commercial insurance carriers. The latest information we have is from an out-of-state laboratory offering a “Client Billing” model to clinicians, by which clinicians can purchase not just the TC but also the PC (clinicians send the specimen bottle to this lab and get a pathology report) for a discounted fee, and then bill commercial carriers for a marked up fee of the global CPT code. We are currently in the process of analyzing our options to denounce this practice.

Website:

Speaking of transformation, that is what our website, http://njpath.org, has experienced in the last year. We have added a wealth of valuable information in new sections such as News, CAP House of Delegates, Job Listings and a Members Only section where you will find legal opinions from John Fanburg, Esq. on Direct Billing laws in New Jersey, a Member Directory, Executive Committee minutes, Legal Reports with extensive information pertinent to the practice of pathology in NJ and contents from Past Seminars.. Please visit it and give us feedback.

Annual Seminars:

The NJSP’s time-honored traditional role has been educational; to provide members excellent lectures from renowned pathologists in various areas of anatomic pathology and laboratory medicine, and that is fine. But times have changed, and they demand more political, legal and financial knowledge. Therefore, we must also provide you with information such as how to increase your revenue, bill for the professional component of clinical pathology, negotiate Part A, negotiate with insurance carriers, add value to your practice and know what options you may have when facing non-traditional business models. This is why we started expanding the fall seminar agenda this year.

It has been a great pleasure serving these two years. Although current times may not be very exciting for us, I believe if we keep ourselves in the right track pathologists will remain a crucial component in the delivery of healthcare.

As a final note, the Executive Committee is looking for members to serve in any function, ideally from various practice types and geographic locations, to enrich its scope of knowledge. If you are interested, please communicate with one of the officers or at http://njpath.org/contact.htm

Thank you,
Edwin Leschhorn, MD
President, New Jersey Society of Pathologists

11/4/21
As I read my President’s report from 2009, I can only get amazed at the evolution of pathology in the last 12 years.

Many gastrointestinal and urology practices have merged and built or expanded in-office pathology laboratories, at the expense of the volume of cases going to traditional laboratories. TC/PC deals have also grown, again to the disadvantage of pathologists giving up usually the majority of the Professional Component.

Molecular Pathology and targeted therapy have become the standard of care, and practically all pathologists have become familiar with which gene abnormalities are important in certain malignant neoplasms, and their therapeutic implications, as well of the importance of proper tissue fixation and preservation.

Our website’s navigation has improved, and you may now renew your membership online.

Finally, the mission of the NJSP, while traditionally educational in Anatomic and Clinical Pathology, needs to also continue focusing on issues such as Part A documentation and negotiation, insurance contracts negotiation, proper CPT and ICD-10 coding, Billing and all its required components, legal implications of various practice models, etc.

Thank you all for your support to the NJSP.

Sincerely,
Edwin Leschhorn, MD
President 2007-2009

Report of the President

“It was the best of times, it was the worst of times…” This famous opening from Dickens’ “A Tale of Two Cities” aptly describes the landscape of pathology as I begin my tenure as president of the society. Pathologists now enjoy great respect from their colleagues, recognition by patients as significant and independent contributors in the health care system, and fair compensation under fee for service reimbursement. However, we appear to be embattled on all fronts. Medicare reductions, insolvent HMO’s, reference lab consolidation, out-patient specimen carve-outs, compliance guidelines, fraud and abuse audits, Part A reimbursement reductions, and finally, the move by hospitals to terminate separate billing agreements and place pathologists as salaried physicians.

It is difficult to be other than pessimistic for the future of pathology. But if we are to remain a respected and independent specialty, we must maintain active and visible roles on our medical staff, our hospital’s administrative hierarchy and our hospital’s PHO. Our physician colleagues and hospital administrators must be made aware of our importance in the health care system, and what is important for us to survive. At every meeting where appropriate, our colleagues must be reminded that our place is alongside the other hospital based physicians such as radiologists and anesthesiologists, and that should pathology slip back into the folds of hospital employment, so will they sooner than later. AS HMO’s gain more power, less surgery will be done in the hospital and more in the physicians office. Our colleagues must be told of our need for access to out-patient specimens, and that no PHO contract should be signed without this provision. Contrary to what the insurers aver, they can sign contracts which permit payment to the hospital pathologist for out-patient specimen interpretations. At Princeton Medical Center, we have this provision written into our contracts with Cigna, United, and Prudential. It is also one of the main sticking points preventing a contract with USHealthcare. The louder and harder we state our needs, the more frequently will they be met.

We must continue active roles in the politic arena, including the state legislature, the CAP, the AMA, and the national legislature. Our elected representatives are often willing to hear of the effects on us and the consumer public of insurance/HMO industry policies. Our representatives are not barricaded behind solid steel doors but rather look to their constituency for information. This past summer, my son and I went to Washington, DC for a 3 day visit. While in the elevator of the capitol building, we were engaged by Senator Thompson of Florida in a 30 minute conversation concerning the Clinton scandal. He was greatly interested in our views to help guide him in his decisions. After all, as he stated, he was elected to represent the people, not just himself. On March 7-9, the annual Federal Key Contact Advocacy School was held in Washington, DC. This was our annual legislative trip to Washington to speak with our senators and representatives. A report on this event from Dr. David Jadwin appears in this issue of the news. Drs. Jadwin, Dise, Epstein and myself also attend the Physicians Public Affairs Conference, the third of which was held on January 20, 1999. I attend the Medicare Clinical Advisory Committee where local Medicare Medical policy is discussed. Only by making our voices heard can we hope to effect change, or at least attempt to ensure survival. I am certain of the outcome should we maintain silence.

On the positive side, our society remains strong. With our bylaws change effected this past November, we have ensured a steady stream of energetic pathologists willing to work for our mutual goals. Membership continues to grow, including Residents in training at our academic institutions. Attendance at our annual meeting remains high (160 registrants) which for a small state is a tremendous validation of the quality of the educational program. I recently read that the annual meeting of the Pennsylvania Association of Pathologists had 50 registrants at their annual meeting (out of 900 pathologists in that state).

It remains a challenge to maintain attendance at the afternoon session of clinical pathology at the annual meeting. In response, the education committee is looking at re-arranging the day’s format to reduce the pressure on the anatomic pathology discussant to finish at a reasonable time before lunch, to ensure adequate exposure for exhibitors, to enliven the legal counsel’s presentation, and to improve attendance at the clinical pathology session. The registration pamphlet, mailed in May, will indicate the format changes. As we approach the new millennium, the challenges appear great, but so will our response.

Notes on Medicare

In case you are not already aware, the re-design of Medicare reimbursement will result in deeper than expected reductions in Medicare pathology payments. As outlined in HCFA’s 1999 physician fee schedule published in November, the use of 1998 RVUs rather than resource based data developed recently by “Clinical Practice Expert Panels” (CPEP) results in a 13 percent overall reduction for pathology phased in over 4 years. HCFA deftly neglected to formally propose the methodology used in the final proposal, thereby preventing public review and comment. HCFA is awaiting validation of the CPEP figures before adjusting the RVUs, however, the use of the CPEP data will only result in an increase in the technical component reimbursement. The CAP representative to HCFA is Stephen N. Bauer, MD, chair of the CAP Professional and Economic Affairs Committee.

Health Care Financing Administration officials stated late February that the agency will increease Medicare payment for manual screening PAP smears to at least $10.42 beginning Jan. 1, 2000. This would represent a 46% increase over the current $7.15 reimbursement. The CAP had asked HCFA to increase the payment to between $13 and $17 . HCFA challenged the CAP and other groups to answer a basic supply and demand question: Why should Medicare pay more for a service when no data exists to indicate that the current payment level has caused an access problem. HCFA urged the participating groups to submit data within the next 30 days that would respond to the market question.

Compliance Issues

In recent years, the office of the Inspector General of the Department of Health and Human Services and the Department of Justice have focused on fraud and abuse enforcement activities. They have been very successful in winning large awards from reference laboratories. They have now determined, through sample reviews, that fraud and abuse is widespread throughout medicine, and are urging participation by medicare beneficiaries in critically reviewing and questioning provider bills and services. Hundreds of law enforcement agents are being hired and trained to review physician practices. As seen in the recent Ameripath situation, you will be judged guilty until proven otherwise. In November, 1998, the government told Ameripath that they were liable for $2.95 million in overpayments caused by improper billings for laboratory services, specifically, the government contended that AmeriPath improperly used 88305 rather than 88304 in billings for skin biopsy interpretations. AmeriPath stock promptly fell by half. In December, the government retrenched somewhat indicating that AmeriPath need not return the monies yet “due to information that was submitted and obtained regarding the potential differing interpretations on how to bill skin biopsies”. It seems that AmeriPath may have been billing correctly for the services. Ameripath stock promptly went back up.

The AMA’s response has been immediate and strident. The government’s complex approach to regulation—and simplistic approach to enforcement—are reminiscent of the worst days of the IRS, when honest taxpayers struggled in vain to decipher the tax code and could only get IRS attention when the auditors were at the door.

The CAP has developed a Compliance Guideline Manual for Pathologists. In the words of Thomas Wood, MD CAP President “Hospital-based pathologists who code and bill for anatomic pathology services and clinical pathology consultations and interpretations should carefully consider how to best meet their responsibility to ensure Medicare billing requirements are met. Pathology practices must also review their operation to avoid violations of anti-kickback and self-referral rules.” A copy of the manual is available to members from the CAP (800-323-4040).

CPT Code Clarification

In the 1999 CPT code edition, there is clarification on the use of codes for breast excisions. 88307 gross and microscopic examination descriptor should be used for breast excisions “requiring microscopic evaluation of surgical margins”, involving work similar to a partial or simple mastectomy. Other breast specimens, such as an incisional or needle biopsy or excision of a discrete lesion (fibroadenoma, eg) not requiring a microscopic examination of the margins would be coded as 88305.

I have asked the CAP to clarify the use of 88307. Should this be used only in the case of a malignancy or in-situ carcinoma, which are the only cases justifying margin review? In their opinion: Whether the final diagnosis is benign or not is not the issue. The issue is whether, on audit, you could justify the evaluation of the margins given what was presented to you when you saw the specimen. If you can, and did evaluate the margins, then code 88307 should be used. If you do not feel that, on audit, you could justify the margin evaluation, then code it 88305 even though you may have evaluated the margins. The operative word in the specimen entry in 88307 is “requiring” evaluation of margins.

This is an excellent situation where compliance guidelines within your department should state your departments practice.

The CPT coding system for PAP smears has been significantly revised for 1999. HCFA is now urging the use of companion codes (HCPCS) to be used with the CPT codes when PAP smears are provided as a diagnostic service, not as a screening service, and when a physician review is required. A copy of the HCFA program memorandum may be seen at the College’s Web site at http://www.cap.org in the Government documents section of the Advocacy page. A summary of the recommendations may be viewed in the January 6, 1999 edition of “STATLINE” on file at the office of the society (contact Cathy Gilmer 609 275-1911).

Professional Affairs

The Board of Medical Examiners has approved for publication new rules governing professional practice structure, kickbacks and self-referrals. The following is a summation of the rules as written by John Fanburg, counsel to our society.

The draft rules will confirm the current position of the Board that health care professionals may use the limited liability company (LLC) and the limited liability partnership (LLP) form of business entity. The new rules will generally maintain the same standard for Fraud and Abuse-Kickback Prohibitions as the current rule. The rule, however, will adopt the Federal “safe harbors” set forth under Medicare Fraud and Abuse Statute. This change will enable practitioners, when structuring business and practices arrangements, to rely on the interpretation of Federal kickback law rather than New Jersey’s somewhat sparse analysis.

The new rules will also place greater restrictions upon practitioners holding the title of “medical or clinical director.” Currently, the consistent on site presence of a medical director is not required. However, the new rule will require medical directors to be present on the premises except where services are rendered by licensed health care personnel who are legally authorized to practice without direct supervision.

· The Board has not yet published the new rules for comment. Upon publication, there will be a period for public comment.