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The CAP's efforts to protect the value of pathology services were adopted by the Centers for Medicare and Medicaid Services (CMS) in two final Medicare regulations affecting reimbursements next year.

The CAP successfully advocated to protect therapeutic apheresis, pathology consultation, and other pathology services targeted for revaluation, resulting in the Medicare program accepting all of the physician work recommendations for pathology services used to calculate professional component and global payment rates in the final 2018 Medicare Physician Fee Schedule. As a member of the American Medical Association (AMA)/Specialty Society Relative Value Advisory Committee, the CAP leads the effort to develop and defend values for pathology services that targeted are for review as potentially misvalued.

The CMS reported that the estimated Medicare physician payment impact on the total allowed charges for pathology and independent laboratories is a -1% in 2018. For individual physicians and practices, the impact depends on mix of services and payers (Medicare and non-Medicare). Physicians receive pay from other Medicare payment systems, for instance, independent laboratories receive 83% of their Medicare revenue from clinical laboratory fee schedule (CLFS).

Details of the impact on pathology services resulting from this final rule are detailed in the CAP's 2018 Medicare Physician Fee Schedule Impact Table.

Learn more about the impact of the 2018 Physician Fee Schedule and the Medicare Hospital Outpatient Prospective Payment System final rule by registering for a webinar on November 9.

Final 2018 Medicare Physician Fee Schedule

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. In the final 2018 Medicare Physician Fee Schedule:

  • The CMS accepted the CAP's recommended increases to the physician work RVUs for six therapeutic apheresis codes (36511, 36512, 36513, 36514, 36516, and 36522), for 2018. The CMS had identified the apheresis codes as potentially misvalued in the 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 and the CMS accepted the CAP's recommendations for 2018.
  • The CMS finalized 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 previously identified the services as potentially misvalued, triggering the review.
  • The CAP advocated at the AMA RUC to maintain and increase the RVUs for diagnostic bone marrow aspiration and biopsy services. The CMS finalized these recommendations. The CMS eliminated 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 final rule includes changes requested by the CAP for the flow cytometry technical component services. The Agency reexamined the 2017 RUC recommended direct practice expense (PE) inputs for these services at the CAP's request and finalized some of the key direct practice expense inputs that the CAP specifically requested. Over the past four years, the CMS has targeted flow cytometry payment in its misvalued code initiative. The CAP worked with the RUC and met with the CMS in an attempt to reinstate some of the previously identified reductions to these codes.

The CAP will engage with the CMS on the final 2018 fee schedule and continue to promote appropriate valuation of pathology services of its published values. The CAP will continue to keep members updated through STATLINE on its work to protect the value of pathology services provided to patients and mitigate potential cuts.

Additional details on the CAP’s specific engagement with the CMS are also available in a September 11 letter. Within this response to the CMS, the CAP urged the CMS to accept the proposed physician work values and well as recommended technical component values for flow cytometry, therapeutic apheresis, and other services.

Feedback on PAMA, CLFS Reporting

The CMS also sought 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).The CMS indicated that comments received would inform the agency regarding potential refinement to the CLFS for future data collection and reporting periods.

The CAP submitted examples of concerns regarding the data collection process as requested by the agency and has called on the CMS to halt implementation of the proposed 2018 CLFS rates to resolve substantive methodological issues. The agency indicated that they will consider the stakeholders’ comments for potential future rulemaking or publication of sub regulatory guidance pertaining to the CLFS data collection and reporting periods.

Final 2018 Hospital Outpatient Prospective Payment System Rule Addresses the CAP’s 14 Day Rule Advocacy

The CMS addressed and agreed in its 2018 Medicare Hospital Outpatient Prospective Payment System (HOPPS) final rule to alter its "14 day rule" policy by adding an additional exception to the Agency's current laboratory date of service (DOS) regulations. The CAP had argued that in order to improve the consistency with Medicare payment policy, that the laboratory date of service (DOS) for all molecular testing should be the date of performance rather than the date of collection. The CAP is pleased that the CMS allowed a new exception to the laboratory DOS policy by permitting laboratories to bill Medicare directly for ADLTs and molecular pathology tests excluded from their packaging policy and ordered less than 14 days following the date of the patient's discharge from the hospital. This new policy applies if the specimen was collected from a hospital outpatient during a hospital outpatient encounter and the test was performed following the patient's discharge from the hospital outpatient department.

The CAP argued for this change in its comments to the 2018 Medicare Hospital Outpatient Prospective Payment System (HOPPS) proposed rule.

Want to Know More—Register for November 9 Webinar on the 2018 Final Physician Fee Schedule Medicare Hospital Outpatient Prospective Payment System Webinar

Learn more about the final 2018 Medicare fee schedule and specific reimbursement changes concerning pathologists during the CAP's November 9 webinar. During this one-hour panel discussion at 1 PM ET/12 PM CT, the CAP's experts will explain the changes in policy and reimbursement for next year. Register now to learn about the CAP's advocacy efforts to impact the CMS' proposal prior to its finalization.

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The CAP continues to ensure that pathologists can successfully participate in the Medicare Quality Payment Program (QPP) as the Centers for Medicare and Medicaid Services (CMS) adopted the CAP's recommended changes to the 2018 QPP final rule. Due to the CAP's work to develop quality measures and create opportunities for pathologists to improve performance in Medicare's quality programs, the CMS estimates that the total positive adjustment for pathology will be $5.6 million in 2020 from QPP participation.

Following recommendations from the CAP to reduce regulatory burden, continue flexibility in the program, and to better reflect the practice of pathology, the Medicare program will maintain the flexibilities for non-patient facing eligible clinicians (ECs), including pathologists, as well as re-weighting of the Advancing Care Information (ACI) and Cost categories of MIPS and flexible reporting requirements in the Improvement Activities (IA) category. Overall, the final 2018 Medicare QPP rule signals that year 2 of the Merit-based Incentive Payment System (MIPS) will include flexibilities while building upon year 1 policies with the CMS aim to prepare clinicians for a robust year 3 program. The CMS also noted hardship exemptions for clinicians in areas affected by Hurricanes Harvey, Irma, and Maria for both 2017 and 2018 performance periods of MIPS.

On November 2, the CMS published its final 2018 QPP rule updates with a comment period to its QPP rule that included updates advocated for by the CAP. Prior to the release of the final rule, the CAP engaged with the CMS and advocated for several changes. The CAP’s Advocacy included comments in an August 21 letter to the CMS that outlined concerns of the ongoing implementation of the 2015 Medicare Access and CHIP Reauthorization Act (MACRA), which included MIPS, Alternative Payment Models (APMs), and other provisions of interest to pathologists.

Learn more and prepare for changes next year by registering for our webinar on November 29.

CAP Advocacy on 2018 MIPS Requirements

The CAP called for key changes to the QPP proposed regulation, and the CMS made the following changes in the final QPP rule:

  • QPP Measure Category: All eight of the CAP's QPP measures were finalized and will continue to be available for pathologists.
  • Qualified Clinical Data Registries (QCDR): The CMS continues to encourage the use of QCDRs like the Pathologists Quality Registry for QPP reporting and participation, including a preference for "non MIPS measures," that are only available in QCDRs. The CAP has a recognized history and expertise in the development of these measures, and has had six such measures previously approved.
  • Re-Weighting of Performance Categories: The CMS will continue to redistribute the weights of the Cost and ACI categories to the quality category for non-patient facing ECs, including pathologists.
  • Low-Volume Threshold: The CAP advocated for relief for small pathology practices and the CMS increased the low-volume threshold to less than or equal to $90,000 in Medicare Part B allowed charges, or less than or equal to 200 Medicare Part B patients.
  • Improvement Activities Category: The CAP advocated with the CMS to keep the requirements minimal for non-patient-facing specialties until the CMS can ensure there are enough activities applicable to these specialties, especially since most pathologists are not able to participate in and are exempt from the Cost and Advancing Care Information (ACI) categories. CMS offers Improvement Activities that are applicable to pathologists. The CAP has assessed the CMS list for pathology-applicable Improvement Activities; more information can be found on our Advocacy website to help pathologists navigate this category.

Moreover, in order to reduce burden and make the program more flexible, the CMS will offer a Virtual Groups participation option and has increased the low-volume threshold so that more small practices and Eligible Clinicians in rural and Health Professional Shortage Areas (HPSAs) will be exempt from MIPS participation The CAP believes these will help pathologists who are in small practices and in rural areas get a reprieve from the reporting burden of MIPS.

In 2018, nearly all pathologists will be required to participate in MIPS. Most pathologists will need to take action to stop penalties from reducing future Medicare payments for their services mandated by MACRA.

A physician's performance in MIPS in 2018 affects his or her Medicare payment in 2020.

The CMS will make payment adjustments from +/-4% starting in 2019 to +/-9% in 2022 and beyond. For the first two years of MIPS, the CMS proposes to reweight categories for non-patient facing specialties without appropriate measures in a category. For pathology, the Cost and Advancing Care Information categories will be weighted at 0% for all eligible clinicians in 2017 and 2018. The CAP is working to ensure pathologists can comply with MIPS, which is the default pathway under the QPP. The CAP is offering reporting options for both the 2017 and the 2018 MIPS performance periods, to help pathologists get the maximum of their Medicare bonus.

Alternative Payment Models

For those Pathologists who practice in an Alternative Payment Model (APM), the final 2018 QPP rule provides more details on how the agency will incentivize those who participate in APMs outside of Medicare, starting in 2019.

The CMS updated polices to encourage Medicare APM participation and are not making changes to the Physician Focused Payment Models (PFPM) definition and PFPM criteria at this time. The agency will consider the feedback received, including APMs with Medicaid and CHIP as payers in the PFPM definition, as they continue to assess and explore ways to provide guidance, as well as additional resources to those developing PFPM proposals.

Register for November 29 Webinar on the Final Medicare Quality Payment Plan Rule

The CAP will review the full details about the final rule in future editions of STATLINE. Moreover, the CAP will host a webinar on the final QPP rule on Wednesday, November 29 at 1 PM ET, moderated by Donald Karcher, MD, FCAP, Chair of the CAP Council on Government and Professional Affairs. Dr. Karcher will be joined by W. Stephen Black-Schaffer MD, FCAP, Chair, of the CAP Economic Affairs Committee and; Diana Cardona, MD, FCAP, Chair of the CAP Economic Affairs Measures & Performance Assessment Subcommittee, who will discuss how these proposed Medicare pay changes under MACRA will affect pathologists in 2018.

Register today.

MIPS Resources

The CAP has a number of MIPS resources to help members to learn more and navigate their Medicare payments, including information about both 2017 and 2018 reporting, a MIPS calculator, an informational video and a MACRA readiness checklist.

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