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Special Report: November 1, 2018 

In This Issue:

The Medicare program finalized recommendations developed by the CAP to increase payment for fibrinolysins interpretation and report services, abandoned a proposed decrease in blood smear interpretation, and accepted payment values for new fine needle aspiration biopsy codes in the final 2019 Medicare Physician Fee Schedule released on November 1.

Overall, the Centers for Medicare & Medicaid Services (CMS) estimates the 2019 fee schedule would result in a 2% decrease to pathology Medicare payments from the 2018 fee schedule. This difference is due to final changes to the practice expense relative value units (RVUs). The impact would vary on individual pathologists depending on their case mix. The impact on pathology services included is detailed in the CAP’s 2019 Final Medicare Physician Fee Schedule Impact Table . CAP members can learn more about fee schedule changes by attending a complimentary webinar on November 9, where CAP experts will review the final 2019 Medicare regulations and their impact on payment for pathology services.

2019 Medicare Physician Fee Schedule

Following the release of the proposed 2019 fee schedule in July, the CAP urged the CMS to accept the CAP-developed physician work RVUs approved and submitted to the agency by the American Medical Association Specialty Society Relative Value Scale Update Committee (RUC). Through its ongoing work to protect the value of pathologists, the CAP led the effort to develop physician work RVUs used to calculate the professional component and global payment. In addition, the CAP developed direct practice expense inputs for pathology services, which is the basis for payment for the technical component as well as global payments.

In the final 2019 fee schedule, specific changes to pathology services included:

  • Fibrinolysins (85390) – The CMS agreed with the CAP recommendation to increase payment for CPT code 85390.
  • Fine Needle Aspiration Biopsy (10004 – 10006) – The CMS agreed with most of the valuation recommendations from the CAP and its coalition partners for the new and revised CPT codes. 
  • Blood Smear Interpretation (85060) –The CMS agreed with the CAP recommendation to maintain payment for CPT code 85060. After a proposed decrease by the Agency, the CAP defended the developed value and urged the CMS to adopt the RUC approved value.
  • Bone Marrow Interpretation (85097) – The CMS did not agree with the CAP recommendation to increase payment for CPT code 85097 and finalized to maintain the current value. The CAP defended the developed value and urged CMS to adopt the RUC approved value.

Impact on Independent Laboratories

For independent laboratories, Medicare physician fee schedule payments are estimated to decrease by 2% in 2019 due to changes to the technical component direct practice expense inputs. This does not reflect the total effect of Medicare changes on independent laboratories, as they receive approximately 83% of their Medicare revenue from clinical laboratory services paid under the clinical laboratory fee schedule (CLFS). 

Evaluation and Management Services

The CAP along with over 170 Medical specialties and the American Medical Association (AMA) urged the CMS to delay finalizing provisions in its Evaluation/Management proposal. As a result, the CMS delayed implementation of key provisions of this proposal until CY 2021. The CMS stated that the delay will allow the agency to work with the AMA and stakeholders to consider any changes made to CPT coding and valuation of new or revised codes.

Clinical Laboratory Fee Schedule Data Collection

The CMS finalized several changes related to the definition of laboratories that must report private sector rates used to set Medicare Clinical Laboratory Fee Schedule (CLFS) payments. The CMS will exclude Medicare Advantage plan payments from total Medicare revenues for purposes of the applicable laboratory definition, which is a change the CAP supports. Additionally, the CMS is finalizing the use of the Form CMS1450 14x TOB to define applicable laboratories.

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Also on November 1, the CMS released the final 2019 Quality Payment Program (QPP) regulation for Year 3. As is the case in 2018, nearly all pathologists will be required to participate in Medicare’s QPP either through Alternative Payment Models (APMs) or the Merit-based Incentive Payment System (MIPS).

The CAP urged the CMS to reduce the burden of complying with MIPS and to make the inherently patient-facing program more flexible for pathologists as non-patient-facing physicians.

In 2019, the CMS will move toward full implementation of MIPS, including increasing the Performance Threshold, retiring several claims-based quality measures, and moving away from claims-based reporting of quality measures.

2019 MIPS Reporting for Pathologists

In 2019, most pathologists will have to act to avoid penalties that reduce future Medicare Part B payments for their services. A physician’s performance in MIPS in 2019 affects Medicare Part B payments in 2021. The CMS will make payment adjustments of +/-7% in 2021 based on performance in 2019. The CMS finalized the following QPP requirements for 2019:

  • Multiple Reporting Mechanisms for Highest Score: The CMS finalized its proposal to allow clinicians to submit a single measure via multiple mechanisms (eg, QCDR and claims) and be scored on the data submission with the higher score. Clinicians who report as a group or are facility-based would also be able to report as individuals to try to maximize their score.
  • More Opportunities to Be Excluded Based on Low-Volume Threshold: In 2019, the CMS is adding a new third criterion to allow individual clinicians and groups to be excluded from MIPS based on low volume. Clinicians or groups would be able to opt-in to MIPS if they meet or exceed one or two, but not all, of the low-volume threshold criterion.
  • Phasing Out Claims-Based Measure Reporting: The CMS also finalized restrictions on claims-based measure reporting. Starting in 2019, claims-based measures can only be submitted by clinicians in small practices (15 or fewer eligible clinicians), whether participating individually or as a group. Individuals or groups in practices with more than 15 clinicians will not be able to report claims-based measures.
  • Pathology Quality Measures: The quality reporting requirements continue to be six measures over one year, with 60% data completeness. The CMS is reducing the number of measures in the MIPS program, and is removing many QPP measures, including the following three of the eight CAP-developed QPP measures:
    • Breast Cancer Resection Reporting
    • Colon Cancer Resection Reporting
    • Quantitative Immunohistochemical (IHC) Evaluation of Human Epidermal Factor Receptor 2 (HER2) Testing in Breast Cancer Patients
  • Increased Performance Threshold: For 2019, the CMS will increase the minimum number of points to avoid a penalty from the current 15 points to 30 points in 2019. Clinicians will have to score above this threshold to be eligible to receive positive payment adjustments. The CMS also increased to 75 points the eligibility for the $500 million exceptional performance bonus pool.
  • Facility-Based Scoring: The CMS is creating an option to use facility-based Quality and Cost performance measures for certain facility-based clinicians who are planning to participate as a group. Facility-based scoring applies for only quality measures and cost categories, so facility-based clinicians would still need to report the Improvement Activities category. The CMS will automatically apply facility-based scoring to MIPS eligible clinicians and groups.

MIPS Resources

The CAP has a number of MIPS resources to help members to learn more and navigate their Medicare payments, including information about 2018 reporting, a list of pathology applicable 2018 Improvement Activities, and an informational video. Email our experts with any additional questions about the Medicare incentive program at

Alternative Payment Models 

In the final 2019 QPP regulation, the CMS increased the Certified Electronic Health Record Technology (CEHRT) use criterion for APMs to qualify as Advanced APMs, which the CAP believes will create additional barriers for Advanced APM participation.

The CMS also finalized Advanced APM requirements such as maintaining the generally applicable revenue-based nominal amount standard at 8% and increasing flexibility in the All-Payer Combination Option.

Finally, the CAP raised concerns that the Physician-Focused Payment Model Technical Advisory Committee (PTAC) was not discussed in the proposed 2019 regulation but was included in the final regulation. The CMS responded by expressing that agency staff have met with stakeholders about proposed models, even though it is unlikely all the features of any PTAC-reviewed model will be tested exactly as presented. The CAP remains concerned that models are being submitted to the PTAC without input of those specialties impacted by the model. The CMS noted they are in the process of developing several new APMs and Advanced APMs and will continue to work with stakeholders on new model concepts.

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To help you successfully navigate these evolving payment models from the final 2019 CMS regulation, the CAP will host the 2019 Final Medicare Policy and Payment Changes webinar on November 9, 2018, at 11 AM ET. Learn how the final regulation will impact payment changes to several pathology services such as fibrinolysins or coagulopathy, fine needle aspiration biopsy, and blood smear interpretation, and how the 2019 QPP regulations may affect burden on practices when implemented. 

Webinar presenters will be Chair of the Council on Government and Professional Affairs Donald S. Karcher, MD, FCAP; Vice-Chair of the Council on Government and Professional Affairs and Chair of the Clinical Data Registry Ad-Hoc Committee Emily E. Volk, MD, FCAP; and Chair of the Economic Affairs Committee W. Stephen Black-Schaffer MD, FCAP. The panel will also answer questions from attendees.

Register today.

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