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On December 28, the Centers for Medicare & Medicare Services (CMS) recognized the Pathologists Quality Registry as a Qualified Clinical Data Registry (QCDR) for the third consecutive year, making the CAP registry a vital tool for pathologists to help complete reporting requirements under Medicare’s Quality Payment Program (QPP) Merit-Based Incentive Payment System (MIPS).

For 2019, the Pathologists Quality Registry offers more pathology-specific quality measures, with 28 quality measures including additional measures for the timely and accurate diagnosis of cancer, bloodstream infections, and heart attacks. In addition, the Pathologists Quality Registry simplifies pathologists’ participation in MIPS by consolidating reporting for both the Quality and the Improvement Activities categories of MIPS and provides real-time performance benchmark reports.

As the CMS continues to move away from claims-based reporting, it will no longer allow practices of 16 or more pathologists to report quality measures on claims via a billing company. The Pathologists Quality Registry not only can support larger practices for their MIPS reporting, but can also help subspecialties of pathology who may find it difficult to identify enough relevant quality measures for MIPS reporting. By submitting data for the 2019 reporting period, MIPS eligible pathologists can avoid a 7% negative payment adjustment and potentially be eligible for a positive payment adjustment in Medicare Part B reimbursement in 2021. Learn more about the 2019 measures and the Pathologists Quality Registry.

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The CAP urged the CMS to reduce the burden of complying with the Quality Payment Program (QPP) and make the inherently patient-facing program more flexible for pathologists as non-patient-facing physicians in 2019. Most pathologists are required to participate in Medicare’s QPP either through the Merit-based Incentive Payment System (MIPS) or Alternative Payment Models (APMs).

For 2019, the CMS increased requirements for compliance with the QPP as the Medicare agency moves more physicians toward full participation in the coming years. The CAP continues to fight on behalf of pathologists on several aspects of the 2019 QPP, which were outlined in a December 21, 2018 letter to the CMS. Specific QPP issues included:

  • Non-Patient Facing Clinicians’ Inability to Fully Participate in QPP: A significant barrier to pathologists’ ability to participate fully in the QPP is that pathologists practice in Laboratory Information Systems (LISs), and most LISs cannot attain Certified Electronic Health Record Technology (CEHRT) status. Thus, pathologists face unique challenges in meeting many of the typical EHR and health information technology requirements in both MIPS and APMs. The CAP requested that the CMS work with the Office of the National Coordinator of Health Information Technology (ONC) and the CAP to adapt its CEHRT requirements to account for LISs to be able to be recognized for purposes of federal payment programs.
  • Opt-In Policy to Participate in MIPS: In 2019, the CMS allows clinicians and groups to opt-in to MIPS if they meet or exceed at least one, but not all three, of the low-volume threshold criteria. The CAP urged the CMS to simplify this new opt-in policy, including clarification on how a pathologist or group would indicate their decision to opt-in.
  • Facility-Based Scoring: The CMS finalized its proposal to allow facility-based measurement based on the Hospital Value-Based Purchasing (VBP) program starting with the 2019 MIPS performance period. Since the CMS will apply the facility-based score automatically to those clinicians who meet the facility-based definition, the CAP asked that the CMS reduce the complexity of the rule by providing information to clinicians to allow them to decide if they should submit quality measures data for MIPS separately to maximize scoring potential.
  • Only Five Pathology–Specific QPP Reporting: The CAP expressed its disappointment that the CMS removed three of the eight pathology QPP measures in the final regulation, leaving pathologists with only five QPP measures in the public domain to report. Since the CMS has maintained a minimum of six measures to be reported for the quality category, the CAP asked the CMS “to update guidance on the Eligible Measure Applicability (EMA) process that determines the number of measures a physician should have reported on when a physician reported on less than the required six quality measures or did not submit an outcome or high priority measure in the quality category of MIPS.”

In addition, the CMS will no longer allow practices of 16 or more pathologists to report quality measures on claims via a billing company. For more information, please reach out to

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On December 26 the CMS extended the discretion period of the laboratory date of service (DOS) exception policy under the Medicare clinical laboratory fee schedule (CLFS) for an additional six months, or until July 1, 2019, due to concerns from stakeholders.

In recent communications with stakeholders who would be affected by the policy, the CMS learned there are still many groups who will not be able to implement the laboratory DOS exception by the original deadline of January 2, 2019. Therefore, the CMS decided that it will continue to exercise enforcement discretion for an additional six months concerning the laboratory DOS exception policy. The CMS will not enforce the requirement that the performing laboratory must bill for advanced diagnostic laboratory tests (ADLTs) and molecular pathology tests excluded from hospital outpatient prospective payment system (OPPS) packaging policy that are subject to the laboratory DOS exception until July 1, 2019.

During the enforcement discretion period, hospitals may continue to bill for advanced diagnostic laboratory tests (ADLTs) and molecular pathology tests that would otherwise be subject to the laboratory DOS exception. Laboratories that are prepared to bill Medicare directly for ADLTs and molecular pathology tests subject to the laboratory DOS exception should do so. Those that are not yet ready should make every effort to comply with the requirements as soon as possible.

The CAP advocated for changes to the 2018 Hospital Outpatient Payment System Regulation 14-day rule, and this enforcement description clarifies what hospitals can bill for and when they can bill for it regarding laboratory test services.

The CMS provided a FAQ document to help laboratories during this extension.

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The National Committee for Quality Assurance (NCQA) and URAC rejected calls by the CAP and the American College of Radiology (ACR) to remedy asserted deficiencies in their respective health plan network adequacy standards. The CAP and ACR actions in support of health plan network adequacy for hospital-based physicians are supported by nine national patient advocacy groups.

In letters sent to the health plan accrediting agencies on October 9, both the CAP and the ACR urged URAC and NCQA to set oversight standards to ensure health plans maintain adequate numbers of in-network providers at hospitals. Noting that current standards by the accrediting agencies are deficient in ensuring network adequacy, the associations point to an American Medical Association (AMA) policy that health plans should be required to document to regulators that they have met requisite standards of network adequacy, including hospital-based physician specialties (ie, radiology, pathology, emergency medicine, anesthesiologists and hospitalists) at in-network facilities and ensure in-network adequacy is both timely and geographically accessible.

The CAP and the ACR also noted that 2015 model legislation on network adequacy endorsed by the National Association of Insurance Commissioners (NAIC) placed a clear obligation on health insurers to declare, as part of their regulatory submission to a state, their “process for monitoring access to physician specialist services in emergency room care, anesthesiology, radiology, hospitalist care and pathology/laboratory services at their participating hospitals.” This provision is adopted by the states of Oregon, Colorado and Connecticut. Other states, including California, New Hampshire and Louisiana, have adopted more stringent network adequacy rules for hospital-based physicians.

In their responses, URAC and NCQA refused to concede any deficiencies in their health plan accreditation standards. In a December 17, 2018 letter to the CAP and the ACR, Tricia Barrett, vice president of design and support for the NCQA, said the committee “works continuously to ensure that health plan members have reasonable access to in-network providers,” adding that most network adequacy oversight is left to the states’ discretion and that only a small portion of states have fully adopted the NAIC model act.

In a November 1, 2018 letter to the CAP and the ACR, URAC President and CEO Kylanne Green stated that URAC’s health plan accreditation standards reflect industry best practices for the development, management and evaluation of a health plan’s network of providers and that the agency would continue to revise its standards through a broad-based stakeholder process that includes both payers and providers.

The CAP, along with the ACR, will continue to fight for more stringent oversight of hospital-based physician network adequacy in health plans.

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The CMS will host an informational call on January 22 at 2 PM ET regarding laboratory requirements for collecting data used to set future Clinical Laboratory Fee Schedule (CLFS) rates. The call will include information about mapping payments to new codes for clinical laboratory tests and other updates. 

During the call, the CMS will review the 14X TOB billing requirements, including laboratory test Healthcare Common Procedure Coding System (HCPCS) codes, associated private payor rates, and volume data requirements.

Under the 2019 CLFS final regulation, applicable laboratories must report to the CMS specific private payer rate information for their component applicable laboratories. The next CLFS data collection period, mandated by the Patient Access to Medicare Act (PAMA), is from January 1 through June 30.

You can register for the call and other informational events through the CMS’ website.

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An accurate diagnosis is perhaps the most critical factor in effective patient care. No one knows this more than you. Connect with and educate legislators and policy experts on the value that pathology brings to the health care continuum.

Register and join us at the:

2019 Policy Meeting
April 29—May 1
Marriott Metro Center, Washington, DC

Make pathology’s impact on patient care heard in Washington.

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