Breaking news: The Centers for Medicare & Medicaid Services (CMS) has released the final 2027 Medicare Physician Fee Schedule and Quality Payment Program regulations.
-
Save the date: Join us November 17 for a webinar reviewing the final Medicare Physician Fee Schedule and Quality Payment Program regulations.
CMS makes no changes to surgical pathology code values for 2027
Following strong CAP advocacy, including a congressional sign-on letter to administration officials, a robust grassroots letter-writing campaign, and extensive formal comments by the CAP, CMS did not finalize cuts to the surgical pathology codes for 2027.
The agency cited a range of concerns received during the comment period, including the potential effect of the proposed changes on beneficiary access to care. CMS concluded that after considering the public comments, it is neither revaluing the codes nor finalizing any changes, but it may take the comments into consideration in future rulemaking.
Background: In the 2027 proposed Medicare fee schedule, CMS said the Maryland Health Care Commission (MHCC) had nominated the surgical pathology code family for revaluation. The MHCC further recommended cuts in payment by up to 90%. CMS had sought comments on whether to revise payments for 2027 or future rulemaking.
What’s next: Should the agency propose additional action in future rulemaking, the CAP will continue to work to make sure that CMS is provided with the most accurate information reflecting the clinical expertise of our practicing physicians.
Stay engaged: The CAP will make sure members are informed about what is happening, why it matters, and what they can do to help.
Immediate impact: Pathology reimbursement will remain under financial pressure in 2027, with other finalized policies projected to reduce Medicare Physician Fee Schedule payments by 2.3%. This decline is largely reflective of the expiration of the 2.5% payment relief provided under the “One Big Beautiful Bill Act.” Medicare reform continues to be an important issue before Congress, and the CAP continues to advocate for a full inflationary update for physicians.
Go deeper: Review our impact table comparing changes to pathology services from current to next year’s payments.
Change needed: The continued decline in pathology reimbursement underscores the need for continued CAP advocacy to stabilize and reform the Medicare physician payment system. Visit the CAP Action Alert Center to urge Congress to take needed steps to stabilize the Medicare Physician Fee Schedule payment system.
How changes to Quality Payment Program rules will affect pathologists next year
For performance year 2027, CMS finalized to:
Sunset traditional Merit-based Incentive Payment System (MIPS) by performance year 2031/payment year 2033.
Make MIPS Value Pathways (MVPs) mandatory starting in performance year 2029/payment year 2031.
-
MVPs are an alternate arm of MIPS with a narrower set of quality measures and Improvement Activities.
-
The Pathology MVP, which became available in 2026, includes other aspects of the MIPS program that do not apply to pathologists such as population health measures and Promoting Interoperability activities.
Define the quality measure set in the Pathology MVP as 7 MIPS Clinical Quality Measures (CQMs) and 3 QCDR measures from the Pathologists Quality Registry as well as 4 QCDR measures from a commercial QCDR, MSN Healthcare Solutions.
-
Many of the Improvement Activities (IAs) included in the MVP are not applicable to pathologists.
-
For information about reporting the MVP, contact mips@cap.org.
Revise the determination of high-priority quality measures.
- Currently, pathologists or groups must report at least one “high-priority” measure, as designated by CMS.
-
Starting in performance year 2027, CMS terminated the “high-priority” designation in favor of a “core measure” designation—clinicians or groups must report at least one “core measure” rather than one “high-priority” measure.
-
Pathology core measures include QPP 396, QPP 440, and QPP 491.
-
Pathologists or groups who cannot report any of these three measures will be required to attest to that fact at the time of reporting.
-
Small practices as defined by CMS (15 clinicians or fewer) are exempt from this requirement.
-
Leave the performance threshold at 75 points as was finalized in the 2026 final rule. The CAP still opposes this high threshold due to the burden on pathologists.
Maintain the data completeness threshold at 75 points, a previously finalized policy.
Add two new CAP-developed IAs applicable to pathologists to the Pathology MVP to support data-driven practice improvement and diagnostic quality enhancement:
-
IA_CC_20: Use of Data to Improve Practice Workflows
Use practice performance and operational data to identify workflow improvement opportunities and enhance the efficiency and quality of care delivery.
-
IA_CC_21: Understand and Improve Diagnostic Performance
Evaluate diagnostic processes and outcomes to support continuous quality improvement, improve diagnostic accuracy, and strengthen patient care.
Remove three IAs from the Pathology MVP and from MIPS:
-
IA_BE_15: Engagement of Patients, Family, and Caregivers in Developing a Plan of Care.
-
IA_CC_12: Care Coordination Agreements that Promote Improvements in Patient Tracking Across Settings.
-
IA_PSPA_2: Participation in Maintenance of Certification (MOC) Part IV.
Determine practices who should be exempt from MIPS due to extreme and uncontrollable circumstances (EUC) automatically instead of requiring an application.
The CAP will advocate for pathologists’ success in the MIPS program. We encourage practices (and their billing companies) to review the scoring changes and contact the CAP at mips@cap.org to understand the availability of higher-scoring measures and how to best report them.
Advanced Alternative Payment Models
For the Advanced APM track, if an eligible clinician participates in an Advanced APM and achieves Qualifying APM Participant (QP) or Partial QP status, they are excluded from the MIPS reporting requirements and payment adjustment.
-
CMS finalized modifications to determination of QPs or Partial QPs to more closely align with MIPS determination at the NPI/TIN level, rather than solely at the NPI level.
-
Additionally, the Consolidated Appropriations Act, 2026, now has provided for a 3.1% APM Incentive payment in 2028 for APM participants.
Save the date: On November 17 we’ll review changes to the 2027 Medicare fee schedule and Quality Payment Program regulations.
More to come: We’re continuing to review the final rule and will share additional details on policies affecting pathologists in future editions of the Advocacy Update.