College of American Pathologists
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August 30, 2012  •  Volume 28, Number 18
Next Issue: September 13, 2012
© 2012 College of American Pathologists

In This Issue:

Pathologists Avoid Meaningful Use Penalties—For Now

Under the final Stage 2 Meaningful Use (MU) rules released last week, pathologists will automatically qualify—and therefore do not have to apply—for the significant hardship exception to payment adjustments based on their Medicare provider status, the College has confirmed. Beginning in 2015, these penalties are applied to providers and hospitals who fail to meet the requirements of the MU program.

The Three Stages of Meaningful Use
  • CMS issued the final rule on Stage 1 in July 2010; implementation began in 2011.
  • Stage 2 takes effect beginning in 2014.
  • Stage 3 is expected to begin in 2016.
  • Penalties begin in 2015 at 1% of a physician’s Medicare payments and could rise to as much as 5% of Medicare payments in 2017 and beyond.

This hardship exception applies to anesthesiology and radiology, in addition to pathology, although it’s unclear how CMS will apply the relief under the agency’s PECOS [Provider Enrollment, Chain and Ownership System], as all three specialties have several codes. The CAP is working with the agency to clarify this issue.

The College had urged the agency to grant this exception, as these three specialties lack face-to-face interactions with patients, and rarely need to follow up with patients. Indeed, the program’s eligible physician (EP) requirements have focused on office-based physicians, not reflecting pathologists’ scope of practice, usual interaction with patients, and type of IT system used in laboratories and practices (an APIS/LIS rather than EHR).

However, in the final rule, CMS indicates that this exception is not permanent, as it will be up for an annual review.

To make this exception permanent, the College is urging lawmakers to support The Health Information Technology Reform Act (H.R. 4066). Introduced by Rep. Tom Price, MD (R-GA), this bill exempts pathologists from eligibility for both Meaningful Use penalties and incentives. To date, CAP has secured 43 co-sponsors and continues to lobby for its enactment.

Rule Specifics

The final rule delayed implementation of Stage 2 from 2013 to 2014 to provide adequate time for vendor and provider compliance. Other pathology-related details in this rule include requiring hospitals and EPs to enter 30% of laboratory orders through Computerized Provider Order Entry (CPOE).

There are several other new requirements of specific interest to pathologists, among other changes:

  • EPs and eligible hospitals must incorporate more than 55% of all laboratory test results into certified EHR technology as structured data. The tests must be ordered by the EP or by authorized providers of the eligible hospital for patients admitted to its inpatient or ER during the reporting period. The results must be either in a positive/negative affirmation or numerical format. This structured reporting was a “menu” objective in Stage 1 and is now a “core”/required objective.
  • Eligible hospitals must provide structured electronic laboratory results to ambulatory ordering providers for more than 20% of electronic laboratory orders received.
  • A new “menu” objective for cancer reporting requires EPs to report case information from Certified EHR technology to a public health cancer registry for the entire EHR reporting period in accordance with applicable law and practice.

The College continues to analyze the impact of the final Stage 2 Meaningful Use rules on pathologists, as well as advocate for permanent exemption under H.R. 4066. Watch Statline for continuing coverage.

Changes Anticipated in Surgical Path Reimbursement in 2013

Reimbursement for certain high volume anatomic pathology codes will likely be reduced beginning in January 2013, as part of CMS efforts to advance initiatives embedded in the health care reform law that scrutinize high volume codes as potentially overvalued while boosting support for primary care services.

Medicare first announced its intention to review the codes as potentially overvalued last year in the 2012 proposed physician fee schedule, and finalized this request for the technical component (TC) of 88305 to undergo review last November in the agency’s final 2012 physician fee schedule regulation. The expected reimbursement changes to the TC of the surgical pathology code family (88300-88309) will be announced in November when CMS releases the Final Physician Fee Schedule for calendar year 2013.

“The Health Care Reform law empowered CMS to review and revalue high volume codes from all specialties as potentially overvalued services,” said Jonathan L. Myles, MD, FCAP, Chair of CAP’s Economic Affairs Committee (EAC). “In 2010, the CAP was able to maintain the value for the PC of 88305 and other surgical pathology codes.”

Last year, CMS flagged the PC and TC of 88305 for review. After the College successfully argued that the 88305 PC had been reviewed as recently as April 2010, CMS limited their request for review to the TC. However, as the TC was originally valued in 2000, scrutiny of the costs associated with this code has been steadily increasing. “The College continues to advocate for appropriate value through the AMA/Specialty Society Relative Value Scale Update Committee [RUC] review process,” stated Dr. Myles, who is the CAP Advisor the RUC.

Be Prepared for Medicare Reimbursement Changes

As these codes are most likely to be revalued, pathologists need to start preparing, advised Mark Synovec, MD, FCAP, a member of the CAP EAC team. “It’s very likely that CMS will decrease the reimbursement of these high volume codes,” explained Dr. Synovec, who practices with the independent group Topeka Pathology Group PA in Kansas. “All pathologists need to be aware that this is likely to happen and assess the impact on their practices.”

The extent of the impact will depend on the nature of each practice’s contracts and billing arrangements. “This is very complex and requires planning and scrutiny of one’s own practice,” said Dr. Synovec, “The impact will depend on the percentage of cases that you are billing the technical component of these services to Medicare, as well as the distribution of the codes used, as the revaluation will likely effect different codes to varying degrees. Knowledge of the code distribution for a practice would aid in planning for anticipated changes.”

Changes in the Medicare TC valuation may affect other billing arrangements such as if your practice dealt with the end of the TC-grandfather exemption by forming a hospital contract linking TC-payments to a percentage of the Medicare rate. “For all of these reasons, even though we don’t know the details until CMS releases the final Physician Fee Schedule in November, if you bill TC at all, these changes will impact you,” explained Dr. Synovec.

Need for Broad ACO Education Efforts Highlighted in CMS Forum

Educating physicians about ACOs must occur at the organizational as well as individual level in order to impact change, asserted CAP ACO Steering Group member James Crawford, MD, PhD, FCAP, in an Open Door Forum hosted this week by the Center for Medicare & Medicaid Innovation (CMMI).

CAP ACO Resources

The online CAP ACO Resource Center features the latest news and information of interest to pathologists on coordinated care, including profiles of members currently participating in these models.

The most recent profile focused on Michael Weldon-Linne, MD, FCAP, with Advocate Healthcare in Chicago. In addition to participating in the Medicare program, Advocate has teamed up with Blue Cross Blue Shield of Illinois as part of a three-year pilot ACO called AdvocateCare. With their “laser focus” on quality and containing costs, AdvocateCare’s pathologists are helping both the system’s private and public ACO achieve its goals.

The Affordable Care Act requires the CMMI to consult with clinical and analytical experts in medicine and health care management, including physicians, when developing coordinated care payment and service delivery models for future testing. Through the forum, CMMI was seeking input from interested stakeholders and the public on how educational opportunities for providers interested in participating in ACOs or other coordinated care initiatives could be designed.

Dr. Crawford is a member of a specialty physician team building an ACO at North Shore-LIJ Health System (NSLIJ), which entails integrating over 2,300 employed physicians and 7,000 affiliated physicians in this $8 billion health system network. In his comments at this CMS Open Door Forum, Dr. Crawford emphasized the need to focus education efforts on two groups of physicians. The first group is those at the organizational level where leaders are familiar with ACOs and aggressively pursuing them, but do still need education. The second group is individual physicians who may not be aggressively pursuing ACOs.

“These physicians don’t have the same level of sophistication on the topic nor time to pour through volumes of information to find out how ACOs affect them,” he explained. “It’s this second group that will truly impact change, so they should not be forgotten. This is true for all individual physicians including pathologists.”

CAP Policy Roundtable Hosting ACO Webinar on Sept. 25

With coordinated care continuing to be central to many health care reform initiatives, it’s crucial for pathologists to define their role and value in these new delivery models. But how to effectively participate is not always clear. The CAP Policy Roundtable’s recently released White Paper, Contributions of Pathologists in ACOs: A Case Study, addresses some of these challenges and an upcoming Webinar will further explore these issues.

Register online for this special CAP-member-only Webinar event, “Thriving in an ACO: How Pathologists Can Confront Challenges and Maximize Opportunities” on Tuesday, September 25, from 2:00 pm-3:0 0pm. One of the CAP members featured in the White Paper, David Scamurra, MD, FCAP, of Catholic Health in western New York, will discuss how his team is developing pathology-related performance measures to improve quality and cost efficiency. White Paper author David J. Gross, PhD, CAP’s Policy Roundtable Director, will also discuss his research findings. Registrants are invited to participate in the Question & Answer session following the presentations.

CMS Pushes ICD-10 Compliance to October 2014

CMS recently finalized a one-year delay for compliance for the ICD-10 code system—from October 2013 to 2014—to allow providers more time to prepare and test their systems.

While expressing appreciation for the one year delay, the AMA urged the agency to do more to reduce the regulatory burdens on physician practices. The group is asking for a two-year delay, as the transition is occurring at the same time as multiple Medicare incentive and penalty programs. The College has supported the AMA’s position.

“Implementing ICD-10 alone requires physicians and their office staff to contend with 68,000 codes—a five-fold increase from the current 13,000 codes,” explained AMA Board Chair Steven J. Stack, M.D in a statement. “Physicians are also already trying to engage in new delivery and payment models.”

Dr. Stack goes on to reiterate the AMA’s commitment to engage the administration on these issues. “This is not the final action on this issus,” he stated. “In the coming months, the AMA will work constructively with the administration to reduce the burden of ICD-10 for physicians so physicians can spend more time with their patients.”

CMS Announces Unique Health Plan Identifier

CMS recently announced it was establishing a unique health plan identifier (HPID), which is expected to save up to $6 billion over 10 years. The HPID is designed to simplify billing transactions between providers and health plans. Currently providers bill health plans that may use a wide range of different identifiers that do not have a standard format. This results in misrouting of transactions, rejection of transactions due to insurance identification errors, and difficulty determining patient eligibility.

The HPID will serve as an “other entity” identifier (OEID), which is for entities that are not health plans, health care providers, or individuals, but that need to be identified in standard transactions. Furthermore, the rule specifies the circumstances under which an organization-covered health care provider, such as a hospital, must require certain non-covered individual health care providers who are prescribers to obtain and disclose a National Provider Identifier (NPI).

In Brief: CDC Now Offering Molecular Genetic Testing Online Course

CDC Now Offering Molecular Genetic Testing Online Course

This Web-based training course is a companion to the “Good Laboratory Practices for Biochemical Genetic Testing and Newborn Screening for Inherited Metabolic Disorders” guidance published in the April 6 issue of Morbidity and Mortality Weekly Report. A forthcoming guidance on technical aspects of quality management using next generation sequencing is currently under review.

Keep Up with the Latest CAP Advocacy News on Twitter

CAP Advocacy is now on Twitter. Follow CAP Advocacy’s daily “tweets” to keep pace with regulatory and legislative news affecting pathology. For the latest health care news, be sure to check out what we are following on Twitter.


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