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The Centers for Medicare and Medicaid Services (CMS) will exercise enforcement discretion with respect to the laboratory date of service (DOS) exception policy under the Medicare clinical laboratory fee schedule (CLFS) until January 2, 2019, the agency announced on July 3.

In 2017, the CMS revised its current laboratory DOS policy for Advanced Diagnostic Laboratory Tests (ADLTs) and for molecular tests that are excluded from the hospital outpatient prospective payment system packaging policy. This meant the performing laboratory may bill and be paid by Medicare directly for these tests. The revision provided an exception to the general laboratory DOS rule: the DOS is the date the specimen was collected so that the DOS for these tests is the date the laboratory test was performed. By adding the exception, the performing laboratory is required to bill Medicare directly for those tests instead of relying on the hospital to bill Medicare on behalf of the laboratory. The hospital would no longer bill for these tests unless the hospital laboratory actually performed the test.

The CAP advocated for changes in 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.

During the enforcement discretion period, hospitals may continue to bill for ADLTs and molecular pathology tests that would otherwise be subject to the new laboratory DOS exception. In such cases, the laboratory would seek payment for the test from the hospital.

Moreover, the CMS will not enforce the requirement that the performing laboratory must bill for ADLTs and molecular pathology tests excluded from hospital outpatient prospective payment system packaging policy that is subject to the new laboratory DOS exception until January 2, 2019. The CMS also published a Frequently Asked Questions (FAQ) which provides further clarification.

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As reported in the July 3 issue of STATLINE, eligible pathologists who submitted 2017 Merit-based Incentive Payment System (MIPS) data through the Quality Payment Program website, can now view their performance feedback and MIPS final score.

Eligible pathologists can access their performance feedback and final score by going to the Quality Payment Program website and logging in using your Enterprise Identity Management (EIDM) credentials. If you don’t have an EIDM account, refer to this guide and start the process now.

The 2019 MIPS Payment Adjustment Fact Sheet highlights how the CMS assigns final scores to MIPS eligible clinicians, and how payment adjustment factors are applied for 2019 based on 2017 MIPS final scores.

The payment adjustments that will be paid out in 2019 are based on this final score. A positive, negative, or neutral payment adjustment will be applied to the Medicare paid amount for covered professional services furnished under the Medicare Physician Fee Schedule in 2019.

Dispute Potential Errors

If you believe an error has been made in your 2019 MIPS payment adjustment calculation, you can request a targeted review from the CMS until September 30, 2018. The following are examples of circumstances in which you may wish to request a targeted review:

  • Errors or data quality issues on the measures and activities you submitted
  • Eligibility issues (eg, you fall below the low-volume threshold and should not have received a payment adjustment)
  • Being erroneously excluded from the Alternative Payment Model (APM) participation list and not being scored under APM scoring standard
  • Not being automatically reweighted even though you qualify for automatic reweighting due to the 2017 extreme and uncontrollable circumstances policy

This is not a comprehensive list of circumstances. The CMS encourages you to submit a request form if you believe a targeted review of your MIPS payment adjustment (or additional MIPS payment adjustment) is warranted.

How to Request a Targeted Review

You can access your MIPS final score and performance feedback and request a targeted review by:

  • Going to the Quality Payment Program website
  • Logging in using your Enterprise Identity Management (EIDM) credentials; these are the same EIDM credentials that allowed you to submit your MIPS data. Please refer to the EIDM User Guide for additional details.

When evaluating a targeted review request, the CMS will require additional documentation to support the request. If your targeted review request is approved, the CMS will update your final score and associated payment adjustment (if applicable), as soon as technically feasible. The CMS will determine the amount of the upward payment adjustments after the conclusion of the targeted review submission period. Please note that targeted review decisions are final and not eligible for further review.

For more information about how to request a targeted review, please refer to the Targeted Review of the 2019 Merit-based Incentive Payment System Payment Adjustment Fact Sheet and the Targeted Review of 2019 MIPS Payment Adjustment User Guide.

1 PM ET/ Noon CT

Register today.

Due to a delay in the CMS’ release of the proposed updates to the 2019 Medicare Physician Fee Schedule and the Quality Payment Program regulations, the CAP rescheduled its webinar providing an in-depth review of the regulations. The webinar will now take place Tuesday, July 24 at 1 PM ET/ Noon CT.

If you are unable to attend the live event, a link to view an archived recording of the presentation will be sent to all registrants following the webinar. The recording can be viewed at your convenience.

Regulation changes will impact payment for services and pathologists’ participation in MIPS. Throughout this 60-minute panel discussion, CAP experts will review the proposed changes to the fee schedule and MIPS. The webinar will begin at 1 PM ET/12 PM CT on July 24. The CMS will finalize the 2019 Physician Fee Schedule and Quality Payment Program regulations during the fall of 2018.

Presenters are:

Donald Karcher, MD, FCAP

Donald S. Karcher, MD, FCAP
Chair of the Council on Government and Professional Affairs

Emily E. Volk, MD, FCAP

Emily E. Volk, MD, FCAP
Vice-Chair of the Council on Government and Professional Affairs
Chair of the CAP Clinical Data Registry Ad-Hoc Committee

W. Stephen Black-Schaffer MD, FCAP

W. Stephen Black-Schaffer MD, FCAP
Chair of the CAP Economic Affairs Committee

Learn and understand the practice and financial implications that these Medicare program changes will have on pathologists in 2019. Register Today.

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