Special Advocacy Update

July 13, 2021

In this Issue:

New CAP-Developed Pathology Consult Codes Proposed for Medicare Payment in 2022

The CAP successfully advocated for the inclusion of new and improved codes and values for pathology consultation services in the proposed 2022 Medicare Physician Fee Schedule.

The CAP had worked with the American Medical Association’s (AMA) CPT Editorial Panel to improve the pathology consultation codes and develop new payment rates through its role in the AMA/Specialty Society Relative Value Scale Update Committee (RUC). The Centers for Medicare & Medicaid Services (CMS) accepted the new code family proposed by the CAP in the 2022 Medicare proposed fee schedule.

Advocacy Win: New Pathology Consultations Codes Added

Each year, the CAP advocates for the valuation of all pathology services. The current pathology consultation services (codes 80500 and 80502) were previously identified as potentially misvalued. Consequently, the CAP worked with the AMA CPT Editorial Panel to delete 80500 and 80502, modernize and create the new Pathology Clinical Consultation family of four codes. Then the CAP worked with the RUC to develop physician work and practice expense values for the new Pathology Clinical Consultation codes. The CAP leads all reviews of pathology services that go before the RUC. Once the fee schedule is finalized, pathologists can begin using the new codes to bill these services in 2022.

As part of the pathology consultation codes review, the CAP analyzed Medicare claims utilization data and observed confusion regarding proper reporting of these services and miscoding. The RUC agreed with the CAP’s request to refer the 80500-code family to the CPT Editorial Panel to develop proper instructions and a CAP proposal for coding structure refinement.

The CAP applauds the CMS proposed decision to implement the new Pathology Clinical Consultation services in 2022. The new pathology clinical consultation services (80XX0, 80XX1, 80XX2, 80XX3) describe physician pathology clinical consultation services provided at the request of another physician or qualified health care professional at the same or another facility or institution.

According to CPT, the pathology clinical consultation services (80XX0, 80XX1, 80XX2, 80XX3) may be reported when the following criteria have been met:

  • The pathologist renders a pathology clinical consultation at the request of a physician or qualified healthcare professional at the same or another institution.
  • The pathology clinical consultation request concerning to pathology and laboratory findings or other relevant clinical or diagnostic information requiring additional medical interpretative judgment.

Proposed Fee Schedule Impact on Pathology Payment

The CMS also estimates the overall impact to pathology payment in 2022 should the agency finalize this rule as proposed. According to the CMS reimbursement for pathology services would decrease by 1% due to changes practice expense pricing. In addition, the proposed 2022 conversion factor used for the fee schedule’s payment formula is $33.5848, representing a 3.75% decrease from the 2021 conversation factor. This 3.75% decrease to the conversion factor stems from Medicare policy to offset increases to other physician services such as any increases to evaluation and management services.

Review all the proposed changes to pathology services in our proposed 2022 Medicare Physician Fee Schedule Impact Table.

What Will Be the Impact of the Proposed Fee Schedule on Your Practice?

CAP members can learn more about the proposed fee schedule changes by attending a complimentary webinar on August 5 at 1 PM ET where experts will review the proposed 2022 Medicare regulations and their impact on payment for pathology services.

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CMS Proposes 2022 Medicare Quality Payment Program Requirements

Also on July 13 the CMS published its proposed 2022 Quality Payment Program (QPP) proposals that will take effect next year. According to the proposed regulation, nearly all pathologists will be required to participate in Medicare’s QPP either through Advanced Alternative Payment Models (APMs) or the Merit-based Incentive Payment System (MIPS).

The CAP has long advocated reducing MIPS reporting burdens for pathologists. In this proposed regulation, the CMS proposed key program changes that move the program forward but also introduce additional complexities. For example, the CMS will move forward with a new participation pathway called MIPS Value Pathways (MVPs). The CMS proposed seven specific MVPs that align with certain clinical topics; however, the CMS will not implement these MVPs until the 2023 MIPS performance period.

The CMS is also soliciting feedback through a Request for Information (RFI) on health data collection to advance health equity for people with Medicare (while protecting individual privacy), potentially through the creation of confidential reports that allow providers to look at patient impact through a variety of data points-including, but not limited to, LGBTQ+, race and ethnicity, dual-eligible beneficiaries, disability, and rural populations. The CAP will be reviewing this closely.

Proposed 2022 MIPS Reporting for Pathologists

In 2022, pathologists eligible for Medicare’s MIPS will have to take action to avoid penalties that reduce future Medicare Part B payments for their services. Performance in MIPS in 2022 affects Medicare Part B payments in 2024 by +/-9%.

In its proposed 2022 QPP regulations, the CMS proposed to increase the Performance Threshold to 75 points from the current 60 points. The CMS also proposed to increase the exceptional Performance Threshold to 89 points from the current 85 points.

The CMS proposed significant scoring changes for quality measures including:

  • Removing the 3-point floor for measures that can be scored against a benchmark. These measures would receive 1-10 points. Measures without a benchmark or that don’t meet case requirements would earn 0 points, with an exception for small practices.
  • Removing bonus points for reporting additional outcome and high priority measures, beyond the 1 required.
  • Establishing a 5-point floor for the first 2 performance periods for new measures, which is in line with the CAP’s advocacy.

The Pathology Specialty Measure Set will remain the same as the 2021 containing six quality measures, including an American Academy of Dermatology (AAD) stewarded measure QPP 440 (Skin Cancer: Biopsy Reporting Time – Pathologist to Clinician). While the CAP recognizes the importance of prompt turnaround of biopsy reports, we are working with the CMS and the AAD to mitigate the operational challenges pathologists encounter when using this measure.

As a direct result of significant advocacy from the CAP, the CMS included a CAP-proposed Improvement Activity on implementation of a laboratory preparedness plan to support continued or expanded patient care during COVID-19 or another public health emergency.

The CAP has actively worked with the CMS to demonstrate the need for more appropriate and alternate measures and improvement activities so that pathologists can more fully participate in MIPS.

Alternative Payment Models

For those pathologists who practice in an Alternative Payment Model (APM), the proposed 2022 QPP makes minimal changes to the Advanced APM track, while adding transition time for accountable care organizations in the Medicare Shared Savings Program (MSSP) to report on certain quality measures and increasing flexibility related to the MSSP quality performance standard.

The CAP will analyze in detail the provisions of the proposed regulation and submit comments during the agency’s 60-day comment period.

What Do The 2022 Proposed QPP Regulations Mean For Your Practice

The CAP will review the provisions included in the proposed regulation during a member-exclusive webinar on August 5 at 1 PM ET.

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