CAP Improves Quality Programs for Pathologists, Makes Gains for Pathology in SGR Bill
Pathologists can now comply with Medicare’s Physician Quality Reporting System (PQRS) without being unfairly penalized.
The College of American of Pathologists (CAP) has secured from the Obama administration additional flexibility for pathologists to participate in PQRS. The flexibility means pathologists can meet the PQRS criteria developed by the Centers for Medicare & Medicaid Services (CMS) and avoid having their Medicare payments reduced.
As a result of CAP advocacy efforts, CMS will add exceptions from PQRS penalties that would otherwise apply to pathologists in 2015 and 2016 under the Medicare quality program.
For example, CMS initially proposed a requirement that physicians must report a total of nine PQRS measures. The CAP advocated for physicians without PQRS measures that fit within the scope of practice to be exempt from penalties. Currently, PQRS has five pathology measures but there still are many pathologists who are unable to participate because the measures are not applicable to their scope of practice. CMS has stated to the CAP that physicians will not be penalized when they report only on the number of measures that apply to their practice. And, if no measures clearly apply, there will be no payment adjustment.
The CAP has produced a webinar with comprehensive information on the 2014 PQRS and the VBM. The webinar is archived and available to view anytime. Additional information also is available at the CAP’s Physician Quality Reporting System Resource Center.
With physician fees set to be cut after March 31, Congress has resumed work on legislation to repeal the sustainable growth rate (SGR) and reform the Medicare payment system, including its quality reporting programs.
Lawmakers have made significant strides on SGR legislation that would tie future payment updates to physician performance on quality programs. On December 5, the House Ways and Means Committee included in its bill a provision that addressed the CAP’s concerns regarding participation PQRS, Electronic Health Record (EHR) Incentive Program, and the Value-Based Modifier (VBM).
“The Ways and Means Committee took a very positive step by including language in its bill to ensure that pathologists can fairly and fully participate in value-based payment programs,” said George F. Kwass, MD, FCAP, chairman of the CAP Council on Government and Professional Affairs. “Current programs have been designed for office-based physicians, but the committee bill would allow flexibility for pathologists to meet quality performance criteria using measures that make sense in the laboratory. We thank committee leadership, especially Chairman Dave Camp (R-MI), and look forward to working with members of Congress to repeal the SGR this year.”
The CAP-supported language in the legislation is needed because the quality programs carry penalties that, under current law, will apply to all physicians beginning in 2017. The provision requires CMS to consult with physician organizations, such as the College, and develop alternative criteria for them to meet the value-based program requirements.
The legislation from the Ways and Means Committee, and a similar bill from the Senate Finance Committee, would combine PQRS, EHR, and VBM programs to create a new value-based performance program. The Finance Committee bill does not include the Ways and Means language supported by the CAP, but Sen. Johnny Isakson (R-GA) secured a commitment from Finance Chairman Max Baucus (D-MT) to add the provision once the bill moves to the Senate floor.
In December 2013, Congress passed a three-month temporary fix to stop SGR cuts of about 24%. The fix provided a 0.5% raise in Medicare pay to physicians through March 31. If a bill to permanently repeal the SGR isn’t passed by the end of March, Congress will have to extend the temporary fix or physicians will again face significant cuts.
CAP: Medicare IHC Payment Policy is Inappropriate for Services Provided to Patients
The CAP has offered CMS evidence to back its position that the agency should make substantial revisions to Medicare policy responsible for steep reductions to payments for immunohistochemistry (IHC) services.
In a January 27 letter to CMS, the CAP provided data to show new and revised CPT codes, and the codes’ values, should be used to pay for IHC in 2014. In the Medicare physician fee schedule, CMS instead required pathologists to use new Medicare created G codes (G0461 and G0462) to bill for IHC services provided to Medicare beneficiaries starting January 1.
The CAP has strongly opposed the change and spoke with CMS to discuss reversing the policy on January 6. CMS had then expressed concern about “current and potential future frequency of immunohistochemical procedures that include multiple, separately identifiable antibodies on the same histologic slide (ie, ‘multiplex antibody stain procedure’)” as a reason for implementing its new payment policy rules for IHC, the CAP summarized in the letter. The vast majority of these procedures are used in the evaluation of prostate needle biopsies to detect carcinoma.
The instances of multiplex IHC procedures are rare. The CAP analyzed data for a small group of members and found a range of 0% to 6.5%, for an average of 2.2%, of these procedures compared to overall cases. In addition, the CAP contacted a major pathology billing company that offered data from 114 pathology groups and the average of all practice cases that used multiplex staining was 3.6%.
“At this time, we are unaware of evolving technologies that would suggest that significant changes to the clinical utilization of these services will emerge in the foreseeable future,” the CAP stated. “Hence the G code language will result in inappropriate reimbursement for immunohistochemistry, because approximately 96% of services that are currently billed use single antibodies on separate slides and only roughly 4% of services use multiplex antibody stain procedures. With the G codes, only the first antibody per specimen will be billed as G0461. This causes a significant undervaluing of the G0462 in a vast majority of cases when subsequent separate antibodies are applied to a different slide.”
The CAP suggested revisions to the G codes that would eliminate the “misaligned add-on designation of G0462.” CMS requires G0461 to report one unit of service per specimen and G0462 to report each additional stain. The CAP proposed changing the description for G0461 to IHC “or immunocytochemistry, per specimen; each single antibody stain procedure" and G0462 to "each multiplex antibody procedure.”
“The modified G-code structure will provide a mechanism for differentiating the additional work and practice expense of this minority of immunohistochemical procedures, limit the potential migration of additional units of service of the add-on code, and provide a mechanism that will allow a crosswalk from the existing corresponding CPT codes,” the letter stated.
The CAP has additional information on payment policy in its Medicare 2014 Physician Fee Schedule Resource Center, including an in-depth fee schedule webinar presentation available online.
Pathologists Improving Quality; Elliott Fisher to Speak at 2014 CAP Policy Meeting
In his keynote address at the 2014 CAP Policy Meeting, Elliott S. Fisher, MD, will speak about the future of health care and how pathologists can help lead during this time of great change in the American health care system.
Dr. Fisher is one of the premier thinkers on improving quality, managing cost, and the challenges and opportunities ahead for the American health care system. A key figure behind accountable care organizations (ACOs), an important component of health care reform, Dr. Fisher is a leading developer of new models of health care delivery and payment. He believes that performance measurement, accountability, well-implemented technology, empowered patients, and partnerships will all play a role in moving health care forward.
ACOs—in which a group of providers is directly held accountable for the total cost and quality of care for an attributed patient population—have emerged as a central feature in the changing face of health care; 52% of Americans are now estimated to live in an area served by an ACO. Dr. Fisher’s current research focuses on exploring the determinants of successful ACO formation and performance. He also codirects the Brookings–Dartmouth ACO Learning Network, in which organizations across the United States contribute to share best practices for ACO implementation.
Future Workforce Issues Addressed in Joint Statement by Pathology and Laboratory Medicine Groups
On January 30, two dozen organizations representing pathology and laboratory medicine released the joint statement “Workforce Issues Affecting Pathology and Laboratory Medicine,” illustrating the workforce issues facing pathology and laboratory medicine under today’s health care system, while outlining recommendations to help pathologists best meet patient needs in the future.
The report is the outcome of the December 2013 Pathology Workforce Summit, which convened, for the first time, representatives from 24 professional pathology and laboratory medicine organizations in Washington, DC, and was sponsored by four major pathology organizations: the CAP, the American Society for Clinical Pathology (ASCP), the Association of Pathology Chairs (APC), and the United States & Canadian Academy of Pathology (USCAP).
Among the meeting’s findings, attendees identified five emerging issues that will impact the pathology work force, including:
- A Decreased Supply of Pathologists and Laboratory Professionals. The supply of pathologists and laboratory professionals will decrease substantially over the next 20 years. According to an analysis published in the Archives of Pathology & Laboratory Medicine, the supply of active pathologists in the US is projected to fall from about 17,600 full-time equivalents (FTE) in 2010 to about 14,000 FTEs in 2030.
- Changes in the Demand for Pathology Services. The demand for pathology and laboratory services over the next 10 to 20 years will be affected by changes in population age and disease incidence. In addition, the mix of services demanded is likely to be affected by new health care technologies and opportunities emerging under ACOs.
- New Factors Requiring Creative Reconsideration of the Nature of Recruitment and Training and Advocacy for Adequate Resources. The number of new pathologists expected to graduate in the next 15 years is far below the number of pathologists expected to leave practice, and current approaches for training pathologists may not be addressing the changing needs for pathology practice. The discipline itself needs to undertake a timely reconsideration of how best to make use of its available training capacity. Attention needs to be directed both to present areas of need such as forensic medicine and to future needs such as pathology informatics and genomic medicine.
- Workforce Projections Must Account for All Members of the Laboratory Team. Laboratory professionals’ roles tend to be technically distinct and complementary, as opposed to subsets, and therefore projections must account for each distinct need or member of the care team.
- Access to Education and Training Opportunities. The availability of training programs will be critical in maintaining and developing an adequate supply of qualified pathologists and laboratory professionals.
In response to these issues, participants agreed on three key recommendations to address future workforce issues: (1) reassessing what every pathologist needs to know and identifying new ways to ensure that adequate numbers of pathologists acquire both general skills and subspecialized expertise, especially in key emerging areas; (2) organizing pathology to attract and recruit highly qualified medical and STEM (science, technology, engineering, and mathematics) students into pathology and laboratory professions; and, (3) reevaluating long-term training expectations to propagate an outlook of lifelong learning to maintain or enhance career opportunities and applicability to current health care delivery systems and payment models.
Moving forward, meeting participants have agreed to adopt the set of recommendations outlined in the joint statement and will continue working together to advance these recommendations for addressing pathology and laboratory medicine workforce issues.
CMS Fixes TC Claims Denials for Same Day Services
Pathologists that receive improper claim denials for the technical component (TC) of pathology services when an outpatient hospital service occurs on the same date of service (DOS) can now resubmit those claims to their Medicare contractors.
The CAP and other stakeholders worked with CMS to resolve this billing issue. As a result, last August CMS issued Transmittal 1276 (Change Request 8399), effective January 6, 2014, which allows pathologists to resubmit their claims for those who can demonstrate that the outpatient hospital service, although occurring on the same day, did not include services for which the hospital would have already been paid for the TC.
When resubmitting a claim, the CAP recommends pathologists include the following:
- A copy of Transmittal 1276,
- A cover letter stating that, based on Transmittal 1276/Change Request 8399, there was a problem with a previous edit, which caused an improper denial on the claim in question, and, whenever possible,
- A copy of the requisition from the ordering physician’s office as additional proof a claim is not related to an outpatient visit (optional).
To learn more about the revision and the appeals process, please visit the CMS website.
Houston Hematopathology Fellow Elected AMA Delegate
The CAP is pleased to announce that Lauren Cooper King, MD, was elected as an American Medical Association (AMA) Resident/Fellow Section (RFS) delegate. Dr. King was elected by residents and fellows from across the country at the AMA’s Interim Meeting November 16, 2013, at National Harbor, Maryland.
As a delegate for the RFS, she will have the opportunity to testify on important issues and assist the AMA RFS Governing Council with representing the voice of residents and fellows in the AMA House of Delegates. A total of 14 sectional delegates and 14 alternate delegates are elected by the RFS each year. Dr. King is currently a hematopathology fellow at Houston Methodist Hospital in Houston, Texas.
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