On July 7, the CMS also published its proposed 2023 Quality Payment Program (QPP) regulation, making limited changes in the traditional Merit-based Incentive Payment System (MIPS) program, but making performance thresholds more challenging for pathologists. The CMS also wants to provide physicians consistency in MIPS while they gain familiarity with CMS’ new MIPS Value Pathways (MVPs) and move over time toward accountable care and advanced alternative payment models. Though limited, the proposed changes to the MIPS program could significantly impact pathologists’ scores and payment bonuses.

In 2023, pathologists reporting MIPS will have to take action to avoid penalties that reduce future Medicare Part B payments for their services. For example, failing to reach the scoring threshold in 2023 could result in Medicare payment penalties up to 9% for payments in 2025.

MIPS Scoring Performance Threshold Remains at 75, but CMS Makes It Harder to Achieve

In the proposed 2023 QPP regulations, the CMS will leave the performance threshold at 75 points. However, the CMS did increase the complexity to reach the scoring threshold, as measures that used to be worth between 3 and 7 points could be worth as little as 1 point. Because the pathology QPP measures are topped out, pathologists must achieve a near-perfect score to get 7 points. Otherwise, if a practice does not achieve a near-perfect score, the practice could receive only 1 point for that measure. Additionally, the exceptional performance bonus pool is no longer available.

The CMS did not change the percentages of cases needed to meet data completeness but proposed to raise this to 75% for 2024 and 2025.

With the proposed 2023 changes to scoring, it is likely that many small practices – especially those that rely heavily on the topped-out QPP measures – could see a reduction in their MIPS performance scores, leading to penalties. Billing companies alone are not able to avoid this problem for many practices. The CAP will advocate for pathologists’ success in the MIPS program.

QPP Measure Updates

The Pathology Specialty Measure Set remains essentially the same, but CMS did propose to add a new measure involving screening for social determinants of health. It is unclear how pathologists can report this measure, and the CAP will provide further guidance to pathologists. Furthermore, the CAP created and submitted a new Mismatch Repair or Microsatellite Instability measure, which was proposed as a new QPP measure and included in the Pathology Specialty Measure Set.

Finally, the CMS is continuing its efforts to implement MIPS Value Pathways (MVPs), although there are no pathology-related MVPs at this time.

The CAP has long advocated to make MIPS reporting less burdensome for pathologists created measures to increase their opportunities to demonstrate the quality they provide and score well in the program. We encourage practices (and their billing companies) to review the scoring changes and contact CAP at mips@cap.org to understand the availability of higher-scoring measures and how to best report them.

Alternative Payment Models

For those pathologists who practice in an Alternative Payment Model (APM), the proposed 2023 QPP regulation makes several changes to reduce the burden and increase opportunities for Advanced APM participation. As a reminder, if an eligible physician participates in an Advanced APM and achieves Qualifying APM Participant (QP) status, they are excluded from the MIPS reporting requirements and payment adjustment. However, because there is no longer an incentive payment for those that become QPs in performance year 2023, which correlates with payment year 2025, the CMS is concerned about the willingness of some eligible physicians to participate in Advanced APMs. Thus, the CMS is seeking input on what, if any, administrative actions would be helpful better to balance the payment incentives within the Quality Payment Program.

Additionally, the CMS made minor clarifying and conforming changes and proposed to make permanent the generally applicable revenue-based nominal amount standard at 8%, which the CAP previously supported.

The CAP will analyze in detail the provisions of the proposed regulation and submit comments during the agency’s 60-day comment period.

What Will Be the Impact of the Proposed Fee Schedule on Your Practice?

CAP members can learn more about the proposed fee schedule changes by attending a complimentary webinar on Monday, August 8 at 1 PM ET where experts will review the proposed 2023 Medicare regulations and their impact on payment for pathology services.

Register today