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Earlier this summer, eligible clinicians and groups began reviewing their 2017 Merit-based Incentive Payment System (MIPS) final scores on the Quality Payment Program website, and requesting targeted reviews from the Centers for Medicare & Medicaid Services (CMS) if there was an error with the 2019 MIPS payment adjustment calculation. The CMS received many requests for targeted reviews, which caused the agency to review concerns regarding the scores. Based on these requests, the CMS identified a few errors in the scoring logic and extended the targeted review deadline to October 15, 2018, at 8:00 PM EDT.

Because of the issues with the scoring logic, the CMS revised the performance feedback on the Quality Payment Program website on September 13. The CAP urges all pathologists to review your performance feedback on the Quality Payment Program website and report any errors with your 2019 MIPS payment adjustment calculation.

The CMS suggested that many non-patient-facing clinicians may not have enough measures or meet the case minimum for any cost measure to be counted, non-patient-facing clinicians are not expressly exempted from the cost category. As such, a pathologist, whether patient-facing or not, meeting the minimum number of cases would have these cost measures attributed and a cost performance score assigned. It is anticipated that most pathologists will have the cost category reweighted to Quality. However, some large practices may have a cost score.

Check if Cost Measures Were Attributed to You

The CAP strongly encourages all participating pathologists check their 2017 MIPS performance feedback to see if you were attributed to any cost measures.

Although cost is reweighted to quality in 2017, the CMS provided feedback if they were able to calculate a cost score for you. Moreover, it is possible that pathologists will be counted in the cost category in 2018 if you were counted in 2017. If you find that the CMS attributed you or your practice to a cost measure in 2017, please contact the CAP at and submit a request to the CMS for a targeted review.

The CMS has resources available on the Quality Payment Program Resource Library to help clinicians understand their performance feedback and the targeted review process. If you are in-need of additional assistance, please reach out to the Quality Payment Program Service Center by phone at 1-866-288-8292, (TTY) 1-877-715-6222 or by email at

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On September 12, the House of Representatives passed the Local Coverage Determination Clarification Act, which aims to improve accountability and transparency in the process Medicare contractors use to make local coverage decisions. Despite this monumental legislation, the CAP is deeply concerned with the House’s removal of a key provision that will weaken the bill.

The CAP strongly advocated for reforms in the original legislation, which would ensure local coverage determinations (LCDs) by Medicare contractors are made by qualified health experts, through a transparent process, based on sound medical evidence.

Key provisions in the bill approved and/or modified by the House include:

  • Open and recorded Medicare Administrative Contractor (MAC) Carrier Advisory Committee meetings.
  • Upfront disclosure of evidence the MACs consider when drafting an LCD, as well as the rationale they are relying on to deny coverage.
  • Additional options for challenging an LCD.
  • Annual reports to Congress on the number of LCD appeals and actions taken in lieu of the creation of an ombudsman.

The House weakened key provisions sought by the CAP that would:

  • Require MACs to independently review LCDs and prevent contractors from rubberstamping another contractor’s LCD.
  • Create a meaningful appeals process that requires a qualified third party make decisions about the validity of reconsideration requests.

CAP President R. Bruce Williams, MD, FCAP expressed disappointment that the House has weakened the bill, but thanked Reps. Lynn Jenkins (R-KS) and Ron Kind (D-WI) for introducing and advocating for the Local Coverage Determination Clarification Act.

The CAP continues to urge the Senate to ensure the bill’s original provisions are preserved, which will further protect patients from arbitrary decisions to deny coverage for Medicare services.

STATLINE will continue to provide updates on the LCD bill.

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During a September 13 hearing, the House Ways and Means Committee reviewed barriers to value-based care, which included the Stark self-referral law, implementation of alternative payment models (APMs), the Physician-Focused Payment Model Technical Advisory Committee (PTAC), and electronic health record (EHR) interoperability. Witnesses providing testimony during the committee hearing stressed the need to reform the Stark law to allow for care coordination efforts. There was also criticism that the CMS has yet to implement a single APM recommended by PTAC.

The CAP has previously stressed that while it is important to assess regulatory obstacles to coordinated care, reform to the Stark law should be approached cautiously. Any reform efforts should include action to close the in-office additional services (IOAS) exception for anatomic pathology (AP) services.

Additionally, for the Medicare Access and CHIP Reauthorization Act (MACRA)’s APM pathway to truly be successful, the CAP states more options are needed that would provide a meaningful opportunity for pathologists’ participation. More innovative health care payment and delivery models must be developed in an open and transparent fashion with the input of those specialties that would be impacted by the models.

“As we have heard from witnesses at other hearings on this topic, taking these models on as a physician or health care system can be a difficult, yet rewarding task,” said Rep. Michael C. Burgess, MD, (R-TX). “Promoting innovation and quality are essential to modernizing American health care and enabling our world-class physicians to focus on providing coordinated, quality care to their patients.”

The CAP will continue to engage with both the Congress and the CMS on these issues.

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Register today for the third MIPS webinar this week.

Diana Cardona, MD, FCAP

As part of our ongoing commitment to ensure pathologists can successfully participate in new and evolving payment models, the CAP continues to offer MIPS educational webinars.

The third in this webinar series, Pathologist Improvement Activities Under MIPS will take place this Thursday, September 20, 2018, at 1 PM ET/ 12 PM CT. During this 30-minute webinar, Diana Cardona, MD, FCAP, will review the pathology-specific improvement activities. Register today.

Other upcoming webinars in the MIPS series are open for registration:

2019 Final Medicare Policy and Payment Changes
W Stephen Black-Schaffer MD, FCAP
Donald S. Karcher, MD, FCAP
Emily Volk, MD, MBA, FCAP
Details coming soon.

Quality Measures that Will Improve Your MIPS Score
Tuesday, December 4, 2018, Noon ET
Diana Cardona, MD, FCAP
Examine ways of improving your performance and MIPS scores using CAP-developed quality measures.

Steps to Take Before Reporting MIPS Data
Tuesday, January 8, 2019, 3PM ET
Emily Volk, MD, MBA, FCAP
Discover ways of maximizing your scoring for 2018 before submitting results to CMS.

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Are you being paid fairly for the services you provide? Payment for pathology services has a direct impact on the success of your practice. Do you know who makes these decisions—and what criteria they use? Are there steps you can take to ensure fair compensation? These topics and more will be explored at CAP18.

Educational Sessions

  • MACRAscopic Analysis of the New Quality Payment Program: Maximize Reimbursement While Demonstrating Value (S1620)
  • How Is My Payment Determined for Pathology Services? Non-CME course (STA008)
  • The CAP’s Policy and Advocacy Agenda (STA010)
  • The Role of Pathologists in Population Health: An Interactive Discussion (STA011)
  • What You Need to Know About the CAP’s Pathologists Quality Registry Non-CME course
  • Lunch Roundtables
    • Current Payment Policy Challenges in Pathology Practice (R1691)
    • My Surgical Pathology and Cytopathology Coding Dilemmas: Getting It Right—An Advanced Discussion (R1690)

Learning Pavilion Sessions

  • Understanding and Maximizing your MIPS Score
  • How to Keep Your Practice Afloat While Reimbursement Rates Decline

CAP Exhibit Booth

  • Pathologists Quality Registry Demos
  • MIPS Resources for Pathologists
  • Billing and Cost Assessment Toolkits

Registration is now open for vital CAP policy and advocacy courses and roundtable discussions during CAP18.

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