For GI Testing, Targeted Panels Meet Today’s Reimbursement Criteria
The importance of diagnostic stewardship in gastrointestinal (GI) testing
Diagnostic stewardship involves more than choosing the correct diagnostic test and technology to deliver the needed clinical result. For clinical laboratory professionals, the objective of diagnostic stewardship is to ensure both the clinical and financial needs of the patient are met by decreasing unnecessary testing and overuse of antibiotics.
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Balancing patient needs and reimbursement realities in GI testing is essential to the clinical laboratory’s responsibility. For example, while large syndromic panel tests once appeared to be an optimal solution for some disease areas, payers’ reluctance (such as Medicare restrictions) to cover such broad tests has been a significant factor limiting their use.
Challenges of including C. diff in large syndromic panels
Thus, the importance of diagnostic stewardship in GI testing and reimbursement is particularly evident today, where GI testing historically has consisted of large syndromic panels that include C. difficile. Unfortunately, this approach can lead to over testing, since 20% of the population is asymptomatically colonized with C. diff, and so detecting this pathogen through broad panel testing often leads to overtreatment for patients whose GI symptoms are caused by something else entirely. Therefore, detecting these asymptomatic cases of C. diff is unhelpful for the patient clinically and financially, and professional organizations such as the Infectious Diseases Society of America (IDSA) recommend against C. diff testing altogether, unless warranted.
The benefits of targeted GI panel testing
Rather, clinicians prefer a more targeted testing option, where differential diagnosis can narrow potential pathogens as the cause of infection and thereby not result in costly over testing and overtreatment. When adapting to a changing reimbursement landscape, targeted GI panel testing as a solution becomes clear, as it shouldn’t be surprising that payers are opposed to reimbursing for these broad tests when they are not necessary. Furthermore, for typical patient populations, clinical laboratory teams are better served by choosing a more targeted GI panel test that does not include C. diff. One option is the VERIGENE® Enteric Pathogens (EP) Test, which meets GI testing guidelines from the IDSA for community-acquired diarrhea.
Choosing a more targeted panel can better serve most patient populations
Selecting a targeted GI panel to maximize reimbursement potential is more important today than ever. After three costly years of the COVID-19 pandemic, payers are exercising caution when it comes to overtesting, so clinical laboratory teams should expect increased scrutiny for any test that may be seen as unnecessary, with large syndromic panels at the top of that list. Medicare is already restricting the use of many targets to avoid overtesting, and other payers are likely to do the same.
Simplifying reimbursement and adapting to changes
Therefore, choosing a more targeted panel can be one of the more effective GI testing strategies for optimized reimbursement, and other single-target tests can be added as needed, such as C. diff testing in specific patients for whom that is appropriate. Starting small and having the opportunity to add on puts labs in a stronger position to meet today’s reimbursement criteria and avoid passing onerous costs onto their patients. This approach also makes it simpler for labs to navigate the frequent changes that occur in coverage determinations. After all, it’s easier and more cost-effective to add a target or two than to scrap an entire syndromic panel and start over.
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