Special Advocacy Update

Read the Special Advocacy Update

• CAP Fights Steep Medicare Cuts to Pathologists Set for 2021; Congress Must Act
• CMS Finalizes 2021 Medicare Quality Payment Program Requirements

In a few weeks, pathologists will be paid 9% less by the Medicare program for the same services they provide to patients today, the Centers for Medicare & Medicaid Services (CMS) confirmed in its final 2021 Medicare Physician Fee Schedule published on December 1. The CAP has opposed the sharp decreases while advocating to protect the value of pathology services. The CAP, as well as a large coalition of specialists who are affected by similar Medicare decreases, has advocated for Congress to intervene, and also led advocacy campaigns rallying support for a legislative fix before the new year.

While the cuts will decrease payment for nearly all pathology services, payment for the molecular interpretation service will more than double because of the CAP’s advocacy. The CMS released the relative value unit (RVU) files to calculate prices for physician services on the fee schedule on December 2. Download the CAP's impact table of the 2021 Medicare Physician Fee Schedule that shows the fluctuations in payment for pathology services between this and next year.

The 9% Medicare cut is a result of budget neutrality requirements that offset the cost of major changes to evaluation and management (E/M) services set to take effect in January. In addition to its advocacy with Congress, the CAP opposed the cuts several times directly with the CMS. This includes the CAP’s comments on the proposed 2021 fee schedule published earlier this year. Read the CAP’s comments on this year’s fee schedule. The final 2021 conversion factor used for the fee schedule’s payment formula is $32.41, representing a 10.20% decrease from the 2020 conversation factor. The exact impact of the decrease to pathology will vary for individual pathologists because of their case mix for patient services.

Increase for Molecular Interpretation Locked In for 2021

Through its ongoing work to protect the value of pathology services, the CAP had recommended new physician work relative value units (RVUs) used to calculate the professional component of Medicare’s molecular interpretation service. Previously identified as potentially misvalued, the service was reviewed by the American Medical Association/Specialty Society Relative Value Update Committee (known as the RUC). The CAP holds the lone seat for pathology on the RUC. The CAP recommended and the AMA RUC agreed to increase the current physician work RVU from 0.37 to 0.93 for the molecular interpretation code G0452. The CMS agreed and proposed to increase the physician work RVUs for G0452 to increase the physician work RVUs for the service by 151%.

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

CAP members can learn more about the final fee schedule changes by attending a complimentary webinar on December 11 at 3 PM ET/ 2 PM CT where experts will review the final 2021 Medicare regulations and their impact on payment for pathology services.

Register today

On December 1, the CMS also published its final 2021 Quality Payment Program (QPP) regulation. According to the final regulation, nearly all pathologists will be required to participate in Medicare’s QPP either through Advanced Alternative Payment Models (APMs) or the Merit-based Incentive Payment System (MIPS).

With the COVID-19 pandemic's impact, the CAP has advocated to reduce MIPS reporting burdens for pathologists. The CMS provided COVID-19 relief for MIPS participants who cannot submit MIPS data in the current performance year (2020). These practices can still submit an extreme and uncontrollable hardship exemption application by December 31, 2020, that the CMS will review on a case by case basis.

Final 2021 MIPS Reporting for Pathologists

In 2021, pathologists reporting MIPS will have to take action to avoid penalties that reduce future Medicare Part B payments for their services. Performance in MIPS in 2021 affects Medicare Part B payments in 2023, by +/-9%.

While the CMS had proposed to increase the Performance Threshold to 50 points from the current 45 points, the Performance Threshold is 60 points as originally finalized in the 2020 QPP Final Rule. The Exceptional Performance Threshold will remain at 85 points.

The Pathology Specialty Measure Set will contain the same six quality measures that it did in 2020. Despite the CAP’s urging the agency to remove Measure 440 (Skin Cancer: Biopsy Reporting Time – Pathologist to Clinician) from the Pathology Measure Set, the CMS finalized to maintain the Pathology Specialty Measure Set as-is for 2021.

The CAP has actively worked with the CMS to demonstrate the need for more appropriate and alternate measures and improvement activities so that pathologists can more fully participate in MIPS and will continue to do so.

In this regulation, the CMS finalized additional COVID-19 reporting relief by delaying implementation of MIPS Value Pathways (MVPs) until 2022. However, additional relief that the CMS had proposed was not finalized. For example, the CMS had proposed not using historical quality measure benchmarks in 2021 and instead only 2021 “current year” performance data in order to avoid skewed benchmarks due to potential COVID impact on data submission. But the CMS determined that sufficient data were submitted for the 2019 performance period that will allow the agency to calculate historical benchmarks for the 2021 performance period.

Alternative Payment Models

For those pathologists who practice in an Alternative Payment Model (APM), the final 2021 QPP regulation confirms a new APM Performance Pathway (APP) composed of a fixed set of measures for each performance category. The APP participation pathway is only for MIPS APM participants and will start in 2021. The agency also finalized minor changes related to the calculation for the QP Threshold Scores used in making Qualifying APM Participant (QP) determinations. Finally, the CMS acknowledged concerns raised by the CAP about changing quality reporting requirements for Shared Savings Program ACOs, so the agency modified proposals to better allow implementation of appropriate infrastructure.

What Do The Final 2021 QPP Regulations Mean For Your Practice

The CAP will review detail the provisions included in the final regulation during a member-exclusive webinar on December 11 at 3 PM ET/ 2 PM CT.

Register today