Special Advocacy Update

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In This Issue:

While the CAP and several physician associations advocated against a new plan providing higher reimbursements for evaluation and management (E/M) services at the expense of specialists like pathologists, the Centers for Medicare and Medicaid Services (CMS) finalized deep payment cuts to pathologists beyond recommendations from the American Medical Association (AMA). On November 1, the CMS announced in the 2020 Medicare Physician Fee Schedule an estimated 8% cut to pathology in 2021. However, the CMS did make favorable changes in response to the CAP’s advocacy on practice expense components tied to pathology payment.

In the final 2020 Medicare Physician Fee Schedule, the CMS estimated that the 2020 changes would result in no overall impact to Medicare spending on pathology compared to the 2019 fee schedule.

The overall impact on an individual pathologist in both the 2020 and 2021 estimates will depend on a physician’s case mix. The effect on individual pathology services for next year is detailed in the CAP’s 2020 Final Medicare Physician Fee Schedule Impact Table.

Evaluation and Management Services 

The 2021 implementation of the CMS’ E/M office visit changes would greatly benefit some physicians, but penalize many who rarely bill for E/M services, including pathologists. Due to budget-neutrality requirements, pathologists and other hospital-based physicians will have large payment reductions to offset the costs to those physicians who deliver more office visit-based services (eg endocrinologists, rheumatologists, and primary care physicians).

The CMS’ proposal goes beyond the AMA’s recommendation and tacks on an additional Medicare add-on code. The CMS stated the additional add-on code was to recognize additional resource costs inherent in furnishing some kinds of office/outpatient E/M visits by primary care physicians. The CAP and the AMA have opposed this additional code, as it accounts for an additional $2.0 billion redistributed to E/M office visit providers away from non-E/M providers, accounting for three percent of the estimated eight percent cut to pathology.

Surgical specialties and the AMA advocated for an increase to the global period of surgical codes to reflect the E/M changes. The CAP strongly opposed this effort, which would have increased the negative impact on pathology, by shifting Medicare spending away from non-facing services (e.g. procedures, imaging, and tests). The final regulation agrees with the CAP and will not make changes to the global surgery codes.

Final 2020 Medicare Physician Fee Schedule

The 2020 regulation will reduce the physician work relative value units (RVUs) used to calculate the professional component of cytopathology screening services. The CAP had recommended to maintain the current physician work RVU of 0.42 for the cytopathology screening services below. The CMS disagreed and recommended to decrease the physician work RVU to 0.26. The CAP secured the support of the AMA and engaged with the CMS to protect the value of the services. However, the agency finalized their initial recommendation to the following services for 2020.

  • Cytopathology, cervical, or vaginal (any reporting system), requiring interpretation by a physician (88141)
  • Screening cytopathology, cervical, or vaginal (any reporting system), collected in preservative fluid, automated thin layer preparation, requiring interpretation by a physician (G0124)
  • Screening cytopathology smears, cervical, or vaginal, performed by an automated system, with manual rescreening, requiring interpretation by a physician (G0141)
  • Screening papanicolaou smear, cervical, or vaginal, up to three smears, requiring interpretation by a physician (P3001)

CAP Success Results in $30 Million Increase For Pathology Services

Because of the CAP’s advocacy and efforts to correct errors affecting Medicare reimbursements for pathology services, the CMS updated 36 direct practice expense supplies and equipment prices, adding $30 million to Medicare payment to pathology services. Twenty-six of these prices increases are due to the direct work of the CAP’s engagement to correct previous errors by the CMS. These prices largely account for the technical component of many pathology services and are also reflected in global payment rates.

What Will Be the Impact of Next Year’s Fee Schedule on Your Practice

CAP members can learn more about fee schedule changes by attending a complimentary webinar on November 8, where experts will review the final 2020 Medicare regulations and their impact on payment for pathology services. Register today.

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Also on November 1, the CMS released the final 2020 Quality Payment Program (QPP) regulation for year 4 of the program. As noted in the final regulation, CAP’s advocacy protected the pathology specific quality measures, and the CMS added an additional measure to the pathology measures set. The CAP successfully advocated to reduce the burden of the Merit-based Incentive Payment System (MIPS), and ensured that pathologists can participate fairly in the program, whether through MIPS or Alternative Payment Models (APMs).

2020 MIPS Reporting for Pathologists

A physician’s performance in MIPS in 2020 affects Medicare Part B payments in 2022. Per the Medicare statute, the CMS will adjust physician payment by +/-9% in 2022 based on performance in 2020.

In its final 2020 QPP regulation, the CMS maintained most of the requirements from 2019, including low volume thresholds, policies for opting in or voluntarily reporting for MIPS, and definitions regarding non-patient facing and facility-based clinicians. However, the CMS specifically finalized for 2020:

  • Pathology Quality Measures: In the final regulation, the CMS retained five of the CAP’s current quality measures within the pathology specialty set and added an additional measure for a total of six quality measures. The CAP successfully worked with the CMS to demonstrate the need for more appropriate measures for pathologists in order to participate in MIPS.
  • Increased data reporting requirements: The CMS increased reporting requirements, including increasing data completeness for quality measures to 70% from the current 60% in 2019. Clinicians or groups not meeting the data completeness requirements will receive 0 points unless they are in a small practice of 15 or fewer clinicians.
  • Increased points to avoid a penalty: For 2020, the CMS increased the Performance Threshold to 45 points from the 30-point threshold in 2019. Clinicians will have to score above this threshold to be eligible to receive positive payment adjustments. The CMS raised the eligibility for the $500 million bonus pool to 85 points.
  • Increase the number of clinicians participating in a group’s Improvement Activities: The CMS increased the participation threshold for group reporting from a single clinician to 50% of the clinicians in the practice, but clinicians can perform the activity during any continuous 90-day period during the performance year. (Everyone does not need to perform the activity at the same time.)

MIPS Value Pathways

The CMS announced that it will begin to implement the MIPS Value Pathways in 2021. The new framework is intended to align measures and activities across the Quality, Cost, Promoting Interoperability, and Improvement Activities performance categories of MIPS for different specialties. The CMS envisions that as this pathway rolls out over the next several years, a clinician or group could be in a MIPS Value Pathway associated with their specialty, reporting on the same measures and activities as other clinicians and groups in that value pathway. The CMS would like to work with medical societies on the development of this new aspect of the Quality Payment Program.

Alternative Payment Models

For those pathologists who participate in an APM, the CMS finalized several adjustments to the Advanced APM track for the 2020 participation year, including changing the definition of “expected expenditures.” By changing the definition will impact how financial risk is calculated under both Advanced APMs and other Payer Advanced APMs.

The CMS chose not to move forward with adjustments that would have impacted those who are “Partial Qualifying Participants” in the Advanced APM track. In comments on the proposed regulation, the CAP expressed concern about this proposal and other changes that would make participation more difficult. The CAP urged the CMS to pursue changes that facilitate more APMs achieving Advanced APM status, and that provide additional opportunities for appropriately-developed physician focused payment models. The CAP will continue to advocate for pathologists’ ability to participate meaningfully in innovative payment models, including urging the CMS to increase opportunity and incentives for specialty physician involvement.

What The 2020 Final QPP Regulations Mean For Your Practice

The CAP will review detail the provisions included in the final regulation during a member-exclusive webinar on November 8 at 1 PM ET. Register today.

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