CAP Opposition to Medicare Cuts Will Persist After SGR Patch
The CAP will continue its work to repeal the flawed Medicare sustainable growth rate (SGR) formula and to reform Medicare’s payment system to reward quality, cost-efficient care.
The CAP opposed recent legislation that only delayed a 24% SGR cut in 2014 to the next year. Congress voted on the “patch” legislation, the “Protecting Access to Medicare Act,” in late March and President Obama signed the bill into law on April 1. This represented the 17th time since 2003 that Congress has stopped an SGR cut temporarily.
The College supports the “SGR Repeal and Medicare Provider Payment Modernization Act of 2014” (HR 4015, S 2000), which included a CAP-supported provision providing pathologists with flexibility and alternative mechanisms for meeting quality requirements in Medicare. The CAP will continue to advocate for a permanent SGR repeal and favorable regulatory and payment policies for pathologists.
The new law with the short-term SGR patch delayed the SGR cut to April 1, 2015. The law did not include the CAP-supported provision regarding Medicare’s quality programs, which include the Physician Quality Reporting System (PQRS), Electronic Health Record (EHR) Incentive, and value-based modifier programs.
The law expands the Centers for Medicare & Medicaid Services’ (CMS) authority to revalue and reexamine potentially misvalued codes for physician services, beginning in 2017. Pathology services would be revalued if they are billed in multiples for a single service, have low relative value units, account for the majority of spending, or differ in payment across different sites of service.
The CAP lobbied successfully in 2013 for the CMS to withdraw a proposal that would have tied Medicare physician payments to rates paid to hospital outpatient departments. The CAP engaged members in a strong grassroots campaign with members of Congress, maintaining that CMS had overstepped its legal authority. But the new patch law may embolden the CMS to propose the policy again.
In another potential threat to pathology payments, the new SGR patch includes CMS-requested language setting a target for net reductions of 0.5% in Medicare’s payment rates. If code revaluation recommendations do not result in payment reductions that reach the target amount, the CMS could further cut payments to physicians until the target is reached.
The target would be applied from 2017 to 2020.
The CAP has expressed strong concern about such enhanced authority for CMS with respect to “misvalued” codes. In particular, the CAP is working to clarify that any expanded code review does not permit CMS to use methodologies for payment other than the resource-based methodology required under current law.
The CAP continues to support the American Medical Association (AMA)/Specialty Society Relative Value Scale Update Committee process for review and valuation of physician services.
The SGR patch bill also included significant reforms to payment for tests on the Medicare Clinical Lab Fee Schedule (CLFS). These reforms overrule a CMS proposal to adjust and likely cut payment for tests on the CLFS due to technological changes. CMS proposed to implement such changes beginning January 1, 2015.
Under the new CLFS reforms, payment rates will be based on the weighted median pay for services from private payers. All government payers and capitated payment arrangements would be excluded from the calculation of the median. Rates would not be subject to an annual update or productivity adjustment. The CMS will collect data on private payer rates from laboratories starting January 1, 2016.
For laboratories with Medicare Part B revenue representing more than half of their total Medicare payments, the new law requires them to send data on their private payer rates every three years. The CMS can set a low volume or low spending threshold to exempt smaller laboratories, but all others would be required to report or face monetary penalties of up to $10,000 per day. In addition, the law creates a new coding and payment pathway for “advanced clinical laboratory diagnostic tests,” defined as FDA-approved tests and multi analyte analyses with algorithms performed by a single laboratory. Those new tests would receive temporary HCPCS codes or unique identifiers which would allow them to be paid by Medicare at a publicly-available market price, starting on the day that the test is first sold. These provisions could disadvantage laboratory-developed tests that do not have FDA approval.
The CAP was pleased to see that the bill limited cuts to CLFS payments to no more than 10% through 2019, and no more than 15% through 2022. Before the bill passed, CMS was not limited to how much it could cut from the CLFS annually.
The CAP is carefully reviewing the new CLFS reforms with an eye toward ensuring a level playing field for all laboratories and mitigating burdensome regulatory reporting requirements.
CAPcast: Why Pathologists Should Attend the 2014 CAP Policy Meeting
Make your voice heard on issues impacting pathologists by attending the 2014 CAP Policy Meeting.
The CAP Council on Government and Professional Affairs chair, George F. Kwass, MD, FCAP, spoke during our latest CAP podcast, CAPcast, about why pathologists should attend the 2014 CAP Policy Meeting. The meeting is an essential event for those interested in learning about emerging policies affecting pathologists.
“Our annual policy meeting is the only national meeting that brings together pathology leaders from all sectors to discuss policy and regulatory issues that impact our profession,” Dr. Kwass said. “In addition, it teaches us crucial skills to become engaged grassroots advocates.”
Contacting members of Congress is exceedingly important during the CAP Policy Meeting and through the CAP’s grassroots initiatives, Dr. Kwass added. Speaking with lawmakers about policy, such as closing the self-referral loophole or reversing Medicare cuts, has a great impact.
May 7 is the Annual CAP Hill Day, which concludes the meeting. On that day pathologists will speak directly with members of Congress on crucial policy decisions that impact pathology. Register for the meeting today.
New CPT Molecular Pathology Code Gene Identifiers Are Now Available
The American Medical Association Current Procedural Terminology (AMA CPT) editorial panel announced a new development in molecular pathology coding.
In addition to the resources that are already available in CPT, a set of official gene abbreviation/identifiers have been created for use in the narrative field of the claims form for Tier 2 Molecular Pathology test codes 81400-81408.
The new CPT molecular pathology code gene identifiers will help providers, payers, and coders during the claims submission process.
These official gene abbreviation/identifiers distinguish the specific analyte tested, which will facilitate adjudication of claims for all stakeholders. This advancement is intended to maximize the utility and directly address concerns of some CPT users of the need for increased granularity in the approximately 550 tests that are associated with these nine codes.
The list was published online on March 12 (Editor’s note: The AMA website requires an active account to access the document. Registering to access the content on the AMA website is free.).
When Given the Chance, Pathologists Shine in Medicare PQRS Program
Pathologists have benefited from new Medicare Physician Quality Reporting System (PQRS) measures developed by the CAP, a review of an April 3 CMS report showed.
The Medicare agency released its report on the 2012 PQRS reporting year, which included three new measures for pathologists. As a result of the new measures, pathologists had more opportunities to report quality activities and earn Medicare incentives. Below are three highlights pertaining to pathologist participation in PQRS from the CMS report.
- Participation: In 2012, 69% of eligible pathologists participated in the program. This was the highest participation rate, and compares favorably to the total eligible physician participation rate of 36%.
- Successful reporting: In 2012, 6,192 pathologists out of 7,050 who participated in the PQRS successfully reported on 50% of their relevant claims. The success rate of 87.8% for pathologists was an improvement on previous years’ success rates for participating pathologists and similar to the overall 2012 success rate for eligible professionals of 85.6%.
- Incentive: The average bonus for pathologists who successfully participated was $398 (range $0.06–$26,505). The average bonus for all physicians who participated was $548 ($457 for all eligible professionals.)
EHR Meaningful Use Penalty Will Not Apply to Independent Laboratories
The CMS has confirmed pathologists at independent laboratories are ineligible for negative payment adjustments under the Medicare Electronic Health Record (EHR) Incentive Program.
A pathologist billing from an independent laboratory—and using the Medicare Provider Enrollment, Chain, and Ownership System (PECOS) code 69—for services is ineligible to participate in the EHR Incentive Program. The CAP had sought clarification on this issue and advocated that no penalty should be assessed.
The incentive program requires physicians to demonstrate meaningful use of EHR technology and is designed with office-based physicians in mind. The CMS provides bonuses to physicians participating in the program. In 2015, the agency will begin penalizing physicians who do not demonstrate meaningful use by imposing a penalty of 1% of the Medicare physician fee schedule covered amount. Penalties increase to 2% in 2016, 3% in 2017, and could increase to as much as 5% in later years.
For pathologists billing only the professional component of Medicare services, and PECOS code 22 on claims, they will automatically be granted a hardship and also will not be penalized in 2015.
Since penalties can last for several years after that, the CAP is advocating that the CMS and the Congress ensure this relief is continued as payment penalties could eventually reach as much as 5% of a pathologist’s Medicare Part B payments. The CAP-supported HR 1309, The Health Information Technology Reform Act, would exclude all pathologists from program eligibility.
The CAP has more details and answers to frequently asked questions about meaningful use in its online Policy Agenda Toolkit.
Complete the 2014 CAP Practice Characteristics Survey
In late April, the CAP will email practicing pathologists and invite them to complete the 2014 CAP Practice Characteristics Survey (PCS). Results from this year’s survey will help the College set advocacy priorities and outline regional market pressures and environmental changes impacting the individual pathologist.
Survey participants will help the CAP to better serve its members. The survey will capture:
- Vital practice member characteristic data
- Information on the concerns and challenges of the CAP member
- Compensation data, including salary and benefits
- Practice-related data
The survey is confidential and can be completed in approximately 10–15 minutes. Practicing pathologists in the US can expect to receive a link to arrive in their email in late April. The email will originate from The Jackson Group, a consulting organization tasked with fielding the survey and tabulating the results.
The CAP will share the survey findings with its members and staff. Like data obtained from prior surveys, the CAP will use the 2014 data in its advocacy efforts with policymakers, health care leaders, and other stakeholders to increase understanding of the significant role of the pathologist in the delivery of patient care. The CAP intends to produce a PCS report and a series of one-pagers with key findings for distribution to key stakeholders.
This survey is available only to CAP members who are currently practicing in the United States. The survey will not include full-time retirees, pathologists practicing in different countries, CAP Junior Members, and pathologists who are full-time US military and/or full-time federal government employees.
After completing the survey, participants will be entered in a weekly prize drawing. Prize winners will have the choice of: 1) a global fee registration (valued at $950) for CAP ’14, 2) a $500 credit for CAP Press publications, or 3) an iPad mini with Retina display. The CAP will hold drawings every week for three weeks. Those who complete the survey during the first week will be entered in drawings for all three weeks.
New York State Agrees With the CAP to Recognize ABP Certification
The state of New York has agreed with the CAP and the American Board of Pathology (ABP) that pathologist certification by ABP could be used as a qualification, in part, for determining state certification of laboratory directorship in laboratories specializing in “Oncology-Molecular and Cellular Tumor Markers.”
The ABP certification, when used by an applicant, would need to be “paired with Board certification in clinical pathology” for purposes of determining eligibility for qualification. The Wadsworth Division of the State Health Department on March 27 communicated its intention to revise state regulations to formally recognize ABP certification, when submitted by laboratory director applicants. The Wadsworth unit also indicated that the regulatory process to implement the change would require some extended time. In January 2013, the CAP joined with ABP in requesting the formal recognition by New York State of the ABP certification.
“Oncology-Molecular and Cellular Tumor Markers” is defined by New York “for laboratories performing tests on cellular material to detect tumor-specific acquired genetic or phenotypic alterations. It includes, but is not limited to, tests that detect chromosomal rearrangements by Southern blot or (RT)-PCR, detection of mutations in oncogenes or tumor suppressor genes (eg, p53) by any technique (eg, sequencing, SSCP, and chip analysis) and detection of altered gene/protein expression by DNA chip analysis, Western blot or any other appropriate semiquantitative technique. Also included in this category is ex vivo determination of chemotherapeutic drug sensitivity.”
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