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Medicare Maintains Values for 'Misvalued' Pathology Services; Proposes Gains for IHC, FISH Add-ons

In the proposed 2017 Medicare Physician Fee Schedule released on July 7, the Centers for Medicare & Medicaid Services (CMS) proposed to maintain the value for several pathology codes targeted as misvalued. The CMS also proposed gains for add-on codes used for immunohistochemistry and immunofluorescence services, which the CAP had strongly advocated for in 2014, 2015 and 2016.

The CMS estimates that changes to the practice expense relative value units used to calculate technical component (TC) and global payments proposed 2017 Medicare Physician Fee Schedule would result in a 2% decrease in pathology services. This estimate shows no overall change in the work relative value unit which comprises the majority of the professional component (PC) payment for pathology services as well as global payments. The decrease stems from proposed changes in the direct practice expense inputs such as medical supplies used to calculate the practice expense relative value units (RVUs).

The physician fee schedule payment received by independent laboratories is estimated to decrease 5% due to these same proposed changes in practice expense costs.

The actual impact upon an individual pathologist or practice will depend on the mix of services provided to beneficiaries with Medicare or other public or private health plan coverage.

The CAP will continue to engage with the CMS on the proposed 2017 fee schedule and seek clarifications to its published values. The CAP will submit formal comments by a September 6 deadline. The CAP will also continue to keep members updated through STATLINE on its work to protect the value of pathology services provided to patients and mitigate potential cuts.

Download the CAP's Impact Table based on CMS' data published on July 7, 2016.

Register for the CAP's July 14 Webinar

Learn more about the proposed 2017 Medicare fee schedule and specific reimbursement changes concerning pathologists during the CAP's July 14 webinar. During this one-hour panel discussion at 2:00 PM ET, the CAP's experts will explain the changes proposed by the CMS. Register now to learn about the CAP's advocacy efforts to impact the CMS' proposal prior to its finalization.

IHC and FISH Add-on codes

Due to the CAP's continued engagement with the agency, the CMS again increased the value of pathology add-on services by reducing their previous discount applied to these codes. Specifically, the CMS proposes to increase the valuation from a 24% discount from the base code to a 20% discount. These physician work RVU increases used to determine the PC payment are proposed for add-on services involving immunohistochemistry, immunofluorescence studies and in situ hybridization. The CAP continues to maintain that for most pathology services, the difference in physician work from the base code to the add-on service is diminutive.

Medicare Prostate Biopsy G-Code

The CAP sought increases to the professional component (PC) of the prostate G-code reported for all prostate biopsy service. As a result of this effort, the CMS proposed to increase the physician work component of G0416 from 3.09 to 3.60. This represents a 17% increase. At the same time, the CMS is proposing further reductions to the TC payment for prostate services.

In 2015, the CMS made a major change in reimbursement policy for prostate biopsy services. The CMS redefined the code G0416 to be reported for all prostate biopsy services. The CMS also requested revaluation and the CAP worked with the RUC to review the code and make physician work and practice expense recommendations for 2017.

Microslide consultations

Also targeted for revaluation are microslide consultation codes 88321, 88323, and 88325. The CAP led the RUC review of the services that involved defending the physician work and practice expense relative value units. The CAP's efforts resulted retaining the current physician work values for 88321 and 88323, and recommended an increase to 88325. The CMS agreed with these recommendations resulting in a 14% increase in the work value for 88325.

Flow Cytometry

The 2016 fee schedule included cuts to flow cytometry codes TC codes 88184 and 88185 as the agency previously identified the services an overvalued. The agency is phasing in further reductions over the next two years. The CAP worked with the RUC and met with CMS in an attempt to reinstate some of the previously identified reductions to these codes. 2017 changes include reductions to the professional and technical component valuations of the flow cytometry codes. The physician work of the flow cytometry codes 88187, 88188, and 88189 are proposed to decrease over 20% each due to CMS' misvalued code initiatives. The practice expense components for flow cytometry are proposed to decrease again for 2017.