College of American Pathologists
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October 10, 2013  •  Volume 29, Number 21
Next Issue: October 24, 2013
© 2013 College of American Pathologists

In This Issue:

While Government Shuts Down, the CAP Continues Advocacy Push

Last week the U.S. government began an incremental shutdown after a Congress bitterly divided over the Affordable Care Act (ACA) failed to reach agreement to fund federal agencies.

But while the government shut down, the CAP has been working on behalf of its members and communicating with Members of Congress and our advocacy partners. As deliberations continue and we await further news of a resolution, the CAP continues to push its advocacy agenda with Members of Congress and senior officials at regulatory agencies such as CMS and FDA, whom are working through the shutdown.

So How Might the Shutdown Affect You?

According to the CAP’s analysis, discretionary programs and federal employees will be the most affected, while payments for Medicare and Medicaid services, insurance exchanges created by the ACA, and other mandatory programs will continue, likely at a slower rate if the government were to undergo a long-term shut down.

For a full analysis of the implications of the shutdown and how it impacts you, visit our website. In the meantime, the CAP is monitoring these changes and will continue to keep our members informed as new updates become available.

113 Members of Congress Sign Joint Letter to CMS Opposing Proposed CMS Cuts

As a result of the strong efforts by CAP members sending emails and making phone calls, the September 18 member “fly-in” on Capitol Hill and efforts by the CAP’s legislative team, 113 Members of Congress have agreed to sign on to a joint letter led by U.S. Rep. Jim Gerlach (R-PA) and U.S. Rep. Bill Pascrell, Jr. (D-NJ), which calls on CMS to withdraw the proposed rule, (CMS-1600-P), which would, if finalized, drastically cut Medicare payments for pathology services. Reps. Gerlach and Pascrell delivered the letter to CMS on Oct. 9.

An additional letter on the issue is currently being circulated within the U.S. Senate. U.S. Senators Johnny Isakson (R-GA) and Amy Klobuchar (D-MN) have agreed to lead the Senate letter.

The CAP Comments in Opposition to Proposed Framework for Pathology CPT Edits in Colorado

On October 4, 2013, the CAP submitted comments to the Colorado Clean Claims Task Force opposing further consideration of a proposed framework for Pathology CPT edits that were released for public comment in September.

In its letter of opposition, the CAP noted that pathologists’ adherence to the requirements in the Final Rule would result in their violating other rules—including other Colorado laws that apply to pathologists. In short, the CAP believes that the Final Rule cannot be applied to pathologists. Thus, the CAP requests that all Pathology and Laboratory CPT codes be removed or exempted from the Colorado Clean Claims project.

A 2010 Colorado law initiated a stakeholder Task Force responsible for establishing a standardized set of coding edits and making recommendations concerning how the set will be implemented, updated and disseminated. The act further requires any person or entity that contracts with a health care provider in Colorado to comply with the act and include the provisions required by the act in the contract. This includes not only commercial health plans but also third-party administrators of self-insured health plans that have contracts with providers in Colorado. Enforcement of the act is by private right of action. The act does not apply to Medicaid and Medicare. The Colorado statute defines a standardized set of coding edits as, “a practice or procedure pursuant to which one or more adjustments are made regarding procedure codes…that results in (a) payment for some, but not all, of the codes; (b) payment for a different code; (c) reduced payment as a result of services provided to a patient that are claimed under more than one code on the same service date; (d) reduced modified payment related to a permissible and legitimate modifier used with a procedure code; or (e) reduced payment based on multiple units of the same code billed for a single date of service.”

The CAP noted, among other substantial objections, that the proposed edits failed to adhere or conform to a 2012 state law that regulates billing for anatomic pathology services. The CAP’s letter concluded that “The CAP does not believe that the Task Force should endeavor to propound any work product regarding pathology services that fails to fulfill the requisite need for veracity, accuracy or legality in the coding for these services.”

Act Now: PQRS Registration Closes October 15

Beginning in 2015, Medicare will penalize providers, including pathologists, who fail to participate in the Physician Quality Reporting System (PQRS).

But there is still time to act! The PQRS registration deadline closes on Tuesday, October 15. To avoid the penalty, you can take the following steps:

  • For members who provide services covered by existing PQRS measures (e.g. breast cancer reporting, colon cancer reporting, prostatectomy reporting, Barrett’s esophagus, and HER2), and who are not yet participating in PQRS, you must report on at least one measure one time before the end of 2013 in order to avoid a -1.5% penalty on Medicare Part B payments in 2015.
  • For members reporting to PQRS as a group, you must register for the Group Practice Reporting Option on the CMS website by October 15, 2013.
  • For members without measures or who do not report at least one measure, sign up for the Administrative Claims option through the CMS website by October 15, 2013 to avoid the 2015 penalty. Instructions are available on the CMS website.
  • For members employed by an independent laboratory that bills using Place of Service (POS) 81, you cannot participate in the PQRS and will not be subject to the penalty in 2015.

To register for either the Administrative Claims Option or for the Group Practice Reporting Option, you will need:

  1. Provider ID Number
  2. Group Taxpayer Identification Number
  3. Medicare IACS Account. For more information, about obtaining an IACS account, visit Additional information regarding registration and obtaining or modifying an IACS account is available at the Self Nomination/Registration web page.

The PQRS registration system, which will close on October 15, can be accessed at and according to October 8 data from CMS, the agency suggests that several hundred group practices who must register have not done so.

Additionally, please note the help desk phone number listed on the PQRS registration portal is incorrect. Users should call the PV-PQRS Help Desk at 1-888-734-6433 and select option 3 for questions about registration. They can also contact CMS’ QualityNet help desk at 1-866-288-8912.

For additional information, visit the CAP Physician Quality Reporting System Resource Center.

The CAP to Submit Comments on Revised Gapfill Pricing of Molecular Diagnostic Codes

In a controversial move, CMS listed only 65 out of 114 new molecular pathology codes in its revised “gapfill” pricing released Sept. 30.

As background, in CY2013, CMS is using the gapfilling methodology to establish payment rates for Molecular Pathology Current Procedural Terminology (CPT) codes being paid using the Clinical Laboratory Fee Schedule.

The gapfilling process requires the Medicare Administrative Contractors (MACs) to set payment rates using a broad range of information outlined in CMS’ Code of Federal Regulations (CFR).

Laboratories that run molecular diagnostic tests were not surprised by the revised reimbursement rates that CMS recently released for new molecular pathology codes, including the 2014 National Limit Amount (NLA). But many stakeholders have questioned CMS’ assertion that MACs can pay a lower rate than the NLA in 2014. On October 1, the American Clinical Laboratory Association (ACLA) released a statement expressing concerns about statements made by CMS noting that “carriers who priced a code below the NLA could continue to reimburse for the code at that lower rate after January 1, 2014 when the NLA is to take effect.”

Further, laboratories are concerned that the agency only posted revised reimbursement rates for 65 of the original 114 new codes slated for pricing under the gapfilling method.

On September 30, CMS also posted to its website a statement that stated, “Only those codes that are currently being paid by the MACs are listed. Some codes listed in the May 9, 2013 posting (CMS posted interim reimbursement rates for 114 new molecular pathology codes established by MACs on May 9) are not currently shown because the service is no longer being paid by the MAC. According to CAP staff, some MACs have indicated that CMS misinterpreted their submissions and that they are paying for some of the unlisted codes, but this discrepancy may not be corrected until the government shutdown ends.”

The CAP is concerned that many proposed contractor coverage decisions would deny beneficiaries’ access to molecular testing that is necessary for their diagnosis and management. On July 8, the CAP submitted a letter requesting that CMS reconsider placement of the molecular pathology services from the Clinical Laboratory Fee Schedule (CLFS) to the Physician Fee Schedule (PFS); provide more transparency into the price determination process by using data approved by the AMA/Specialty Society Relative Value Scale Update Committee (RUC); and provide greater coverage for molecular pathology tests necessary for diagnosis and patient management, in order to improve patient access to these services.

The public will have until October 30 to request reconsideration of the NLAs listed in the revised payment amounts, which were posted September 30. The CAP’s Economic Affairs Committee within CGPA is working with the Association for Molecular Pathology (AMP) and the American Medical Association (AMA) to submit joint comments on this issue.

CMS Has No Short-Term Plans to Clarify Date-of-Service Rule for Professional Component Billing of Diagnostic Tests

The Wisconsin Physician Services (WPS), the Medicare Administrative Contractors (MAC) for Medicare jurisdiction 5 (Iowa, Kansas, Missouri and Nebraska) and jurisdiction 8 (Indiana and Michigan) recently announced changes to its date-of-service policy that will have an impact on how anatomic pathology (AP) services are billed.

WPS has instructed providers billing Medicare part B that the billing date for professional component services should be the date that the pathologist actually provides the interpretation. When the technical and professional components are performed on different days, each component should reflect the actual date performed. According to WPS, this shift in policy is based on their interpretation of Medicare guidelines.

Currently, most labs that perform both the technical component (TC) and the professional component (PC) for AP specimens submit a global charge to their CMS contractor with the same date of service (DOS) for both components.

The Kansas Medical Society has expressed disagreement with WPS’ interpretation and in a March 2013 letter to CMS requested clarification of the date of service rule for professional component billing of diagnostic tests. A senior staff member at CMS stated the agency “does not currently have a date-of-service policy and that it is up to the local MACs to establish policy for their respective jurisdictions.” CMS also noted that due to a busy agenda, they have no short-term plans to address this issue.

The CAP recommends that all members familiarize themselves with their local MAC policy to avoid future claim denials.


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