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July 13, 2017

CAP’s Advocacy on Pathology Payment Reflected in Proposed 2018 Medicare Fee Schedule

In the Centers for Medicare & Medicaid Services' (CMS) proposed 2018 Medicare Physician Fee Schedule released July 13, the agency proposed to accept all of the recommendations from the CAP and AMA Specialty Society Relative Value Scale Update Committee (RUC) for physician work relative values to certain pathology services. Some of these recommendations reflected increases from current values.

The CMS estimates that changes to the physician work and practice expense work relative value units (RVUs) used to calculate global and technical component (TC) payments, as proposed for the 2018 Medicare Physician Fee Schedule would result in a 1% overall decrease in pathology services. This impact would vary on individual pathologists depending on their case mix.

The proposed physician fee schedule payment received by independent laboratories is estimated to decrease 2% due to the proposed changes to the technical component direct practice expense inputs.

The CAP will continue to engage with the CMS on the proposed 2018 physician fee schedule and seek clarifications to its published values. The CAP will submit formal comments by the September 11 deadline. The CAP will keep members updated through STATLINE on its work to protect the value of pathology services.

Download the CAP's Impact Table based on CMS' data published on July 13.

Register for the July 17 Webinar

This Monday, July 17 learn more about the proposed 2018 Medicare Physician Fee Schedule and specific reimbursement changes concerning pathologists during the CAP’s Pathology Payment – An Overview of the 2018 Proposed Medicare Physician Fee Schedule webinar. On the July 17 webinar at 1:00 pm ET, the CAP's experts will review and explain the CMS proposed changes. Register now to learn more about the CAP's advocacy efforts to influence the CMS' proposal prior to its finalization.

Proposed Values and Practice Expense

The CAP defended and sought increases to the existing physician work relative value units (RVUs) and the direct practice expense inputs for four sets of pathology services.

  • The CMS accepted the CAP’s recommended increases to the physician work relative values (RVUs) for six therapeutic apheresis codes (36511, 36512, 36513, 36514, 36516, and 36522), for CY 2018. The CMS identified the apheresis codes as potentially misvalued in the CY 2016 PFS proposed rule.
  • The CAP also successfully defended against a potential decrease in the work RVUs for pathology consultation during surgery codes 88333 and 88334.The CMS identified these services in the 2014 proposed fee schedule as potentially misvalued. The CAP defended the codes before the AMA RUC and recommend maintaining the current physician work RVUs. The CMS is proposing to accept these recommendations for CY 2018.
  • The CMS proposes to accept the recommended work RVUs for two tumor immunohistochemistry codes (88360 and 88361) and made changes to direct practice expense inputs that the RUC recommended. The CMS also identified the services as potentially misvalued through a high expenditure screen across specialties.
  • The CAP advocated that the AMA RUC maintain and increase the RVUs for diagnostic bone marrow aspiration and biopsy services. The CMS is also proposing to accept these recommendations. The CMS is also proposing to eliminate HCPCS code G0364 – Bone marrow aspiration performed with bone marrow biopsy through the same incision on the same date of service due to CPT changes to this code family.

Flow Cytometry

The CMS also proposed to reexamine payment for flow cytometry technical component services based on stakeholder comments. The practice expense components for flow cytometry technical component service 88185 is proposed to decrease again next year as the CMS continues to phase-in its reduction to this service.

Proposed Changes to Quality Programs

The CMS is proposing to change the current Physician Quality Reporting System (PQRS) requirements from reporting of nine measures across three National Quality Strategy domains to reporting of six measures with no domain requirements. Since 2016 was the last reporting period for PQRS, the CMS is not proposing to collect additional data. The CMS will apply the new proposed criteria to data that was submitted by Eligible Professionals in 2016, which will affect payment in 2018.

The CMS is also proposing to ease Value-Based Modifier (VBM) penalties for 2018.

The CAP is working with the CMS to ease the PQRS and VBM requirements and penalties in order to better align these programs with the new Merit-based Incentive Payment System (MIPS) under the Quality Payment Program (QPP). The CMS indicated that this change is based on stakeholder, such as the CAP, feedback. Reporting on MIPS began on January 1, 2017, and will affect 2019 payment.

Regulatory Burden Reduction of Physicians

In the proposed rule, the CMS also released a Request for Information (RFI) to gain information on achieving better transparency, flexibility; program simplification and innovation in the current healthcare delivery system. The CMS would also like to reduce the regulatory burden that is currently placed on clinicians, providers, and patients. While the agency will not specifically respond to submissions in the Final Rule, they plan to develop future regulatory proposals aimed at reducing regulatory burdens. The CAP is actively engaged with the Department of Health and Human Services to increase transparency and reduce regulatory burdens on pathologists. The CAP welcomes this opportunity to further engage with the CMS on this matter.

Feedback Needed on PAMA, CLFS Reporting

The CMS is seeking comments from laboratories and reporting entities regarding their experience with the first data collection and reporting periods under the new private payer rate-based clinical laboratory fee schedule (CLFS). Comments received would inform the CMS regarding potential refinement to the CLFS for future data collection and reporting periods. The CAP continues to engage with the CMS regarding concerns over the data collection and new clinical laboratory fees as the Medicare agency implements changes to the CLFS mandated by the Protecting Access to Medicare Act (PAMA) of 2014.