CAP Advocacy Secures Increases for Cancer Coverage and Physician Reimbursement

Newly released payment regulations from the Centers for Medicare & Medicaid Services (CMS) include additional payment and expanded coverage policies advocated for by the CAP. Following the CAP’s initial analysis on November 1, there are more changes affecting pathologists and laboratories detailed in the 2025 final Physician Fee Schedule and Quality Payment Program Regulation and the Hospital Outpatient Prospective Payment System (HOPPS) and Ambulatory Surgical Center Payment System Final Rule.

CAP Defeats Hospital Payment Change

The CMS had proposed to move surgical pathology tissue exam by a pathologist (CPT code 88309) to the lower Ambulatory Payment Classification (APC) 5673 “Level 3 Pathology” from APC 5674 “Level 4 Pathology.” If this proposed change had been finalized, it would have resulted in a 57% decrease in the payment amount and would not have aligned with the much more complex set of resources required to examine these specimens.

The CAP argued in a letter to the CMS that the service includes complex Level VI surgical pathology evaluation representing the most complex surgical pathology tissue examinations by pathologists requiring arduous specimen preparation. Additionally, the proposed reassignment created a resource cost rank order anomaly with other physician services (such as CPT code 88307 APC 5673 “Level 3 Pathology”) and the technical costs will not be fully recovered from each unit of service. The CAP stated that the unique complexity of specimens associated with these services warrants a level 4 pathology APC.

Because of the CAP’s advocacy efforts, the CMS maintained the APC assignment of APC 5674 for CPT code 88309 which was finalized by the CMS in the HOPPS Final Rule.

Expansion of Colorectal Cancer Coverage

Beginning on January 1, 2025, the CMS will expand its coverage of screening services for colorectal cancer to include Computed Tomography Colonography. The CAP supported previous proposals to expand coverage of colorectal cancer screening coverage. Expansion would directly advance health equity by promoting access and removing barriers for much needed cancer prevention and early detection within rural communities and communities of color that are especially impacted by the incidence of colorectal cancer, the CAP said in a letter to the CMS on September 9.

Additionally, the CMS finalized a proposal to remove coverage of double contrast barium enema. Finally, complete colorectal cancer screening tests that include a follow-on screening colonoscopy after a Medicare covered non-invasive stool-based colorectal screening test, or a Medicare covered blood-based biomarker screening, will not have to pay cost-sharing for the follow-on colonoscopy.

Fine Needle Aspiration Codes Not Misvalued

In the 2025 Medicare Physician Fee Schedule, the CMS noted that an interested party previously nominated fine needle aspiration services, CPT codes 10004, 10005, 10006, and 10021, as potentially misvalued and suggested that they should be re-reviewed. The CAP had stated in a letter to the CMS, that these codes were not potentially misvalued and therefore should not be re-evaluated. In the final rule, the CMS agreed with the CAP and indicated are not potentially misvalued.