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- CAP Urges CMS to Maintain Current APC level for CPT Code in Final Hospital Outpatient Regulation
The CAP asked the Centers for Medicare & Medicaid Services (CMS) to reevaluate the ambulatory payment classification (APC) for clinical CAR-T services proposed 2025 Hospital Outpatient Prospective Payment System and Ambulatory Surgery Center Payment System regulations. The CAP advocates fair payment for all services pathologists provide—actively representing pathologists’ interests in every payment-related policy discussion.
Separate and Distinct Payment for CAR-T Service
In the September 9 comment letter to the CMS, the CAP argued that these clinical services occur months to weeks in advance of potential CAR-T cell infusion, and are distinct services separate from the manufacturing of the CAR-T cell product. Therefore, they should be allowed to be reported and paid separately at the time they occur. Further, each service is distinct with their own unique costs, liabilities, and clinical tasks. In its’ comments to CMS, the CAP urges the CMS to treat CAR-T services as separate and distinct physician services on the HOPPS by assigning payable status indicators and unique APC payments.
Ambulatory Payment Classification (APC) Level Changes
The CMS is proposing to move surgical pathology tissue exam by pathologist (CPT code 88309) to APC 5673 “Level 3 Pathology” from APC 5674 “Level 4 Pathology”. The CAP disagrees with this proposed change to the APC for CPT code 88309. The CAP believes the data leading to this change in APC level must be flawed. The CMS’s proposed change represents a 57% decrease in the payment amount and does not align with the much more complex set of resources required to examine these specimens. The CAP is urging CMS not to finalize this change and instead maintain the current Level 4 APC assignment.