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For 2019 payment changes to pathology services, the Medicare program has proposed to accept several recommendations developed by the CAP and the AMA Specialty Society Relative Value Scale Update Committee for services provided by pathologists, such as CPT code fibrinolysins or coagulopathy screen, interpretation and report and some new fine needle aspiration services. In some instances, the recommendations reflect increases from current values for physician work.

In the proposed 2019 Medicare Physician Fee Schedule released July 12, the Centers for Medicare & Medicaid Services (CMS) estimates the proposed changes would result in a 1% decrease to pathology services from the 2018 fee schedule. This difference is due to proposed changes to the practice expense relative value units (RVUs). The impact would vary on individual pathologists depending on their case mix.

The proposed physician fee schedule payment received by independent laboratories is estimated to increase by 4% due to the proposed changes to the technical component direct practice expense inputs. This impact does not reflect the total Medicare impact on independent laboratories as they receive approximately 83% of their Medicare revenue from clinical laboratory services paid under the clinical laboratory fee schedule (CLFS).

The 4% increase is largely due to the CMS’ proposed use of revised direct practice expense prices for supplies and equipment for 2019. These prices were last revised in 2004-2005. If finalized, the change would be phased over a four-year period beginning in 2019 and would impact the total professional and technical component reimbursement of pathology services.

The impact on pathology services included in this proposed regulation is detailed in the CAP’s 2019 Proposed Medicare Physician Fee Schedule Impact Table.

Proposed 2019 Medicare Physician Fee Schedule

As the pathology advocate before the AMA RUC, the CAP led the effort to develop and defend values for both new and revised codes and pathology services that were targeted for review as potentially misvalued. Through its ongoing work to protect the value of pathologists, the CAP recommended physician work RVUs used to calculate the professional component and the direct practice expense inputs for pathology services which impacts payment for the technical component. The CMS took the following actions in the proposed 2019 Medicare Physician Fee Schedule:

  • Fibrinolysins (85390) – The CMS agreed with the CAP recommendation to increase payment for CPT code 85390.
  • Fine Needle Aspiration Biopsy (10X11, 10X13) – The CMS agreed with the recommendations from the CAP and its coalition partners for the new and revised CPT codes.
  • Blood Smear Interpretation (85060) –The CMS did not agree with the CAP recommendation to maintain payment for CPT code 85060 and proposed a reduced value.
  • Bone Marrow Interpretation (85097) – The CMS did not agree with the CAP recommendation to increase payment for CPT code 85097 and proposed to maintain the current value.
CMS Seeks Input to Improve Data Collection for CLFS Rates

In response to concern that the initial data collection of private sector clinical laboratory rates used to calculate new payments for the 2018 Medicare CLFS excluded many classes of laboratories, the CMS is seeking input on alternative approaches for expanding the definition of applicable laboratories. Beginning January 1, 2018, the payment amount for a test on the CLFS is generally equal to the weighted median of private payer rates determined for the test, based on the data collected by the agency from “applicable laboratories” during the data collection period. The CAP and other stakeholders believe that the 2018 CLFS payment rates are based on information from a subset of laboratories and have urged the CMS to expand this definition.

The CAP will engage with the CMS as the agency works to finalize the 2019 physician fee schedule, and will keep members informed through STATLINE on its work to protect the value of pathology services. CAP members are encouraged to attend the July 24 webinar where CAP experts will review both proposed 2019 regulations and their impact on payment for pathology services.

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Also on July 12, the CMS published its 2019 Quality Payment Program (QPP) proposals for Year 3 of the program. As is the case in 2018, nearly all pathologists will be required to participate in Medicare’s QPP either through Alternative Payment Models (APM) or the Merit-based Incentive Payment System (MIPS).

The CAP met with the CMS several times in 2018 to advocate for the CMS to reduce the burden of complying with MIPS, to ensure that pathologists can achieve full points, and make the program more flexible.

The CMS described Year 3 proposals for the QPP as historic, based on the administration’s regulatory relief initiatives. The 2019 QPP proposed rule implements the CMS’ Patients over Paperwork and Meaningful Measures initiatives as well as the Bipartisan Budget Act of 2018.

2019 MIPS Reporting for Pathologists

In 2019, most pathologists will have to take action 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. As per the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) statute, the CMS will make payment adjustments of +/-7% in 2021 based on performance in 2019. The CMS specifically proposed for 2019:

  • Pathology Quality Measures: In contrast to what the agency published in the 2018 final rule for phasing out topped-out measures over several years, the CMS proposed the removal of 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

    In addition, the CMS has disadvantaged measure developers like the CAP who have invested significant resources in measure development by proposing that all measures be made available for free to other Qualified Clinical Data Registry (QCDRs).

    In 2019, the CMS proposed that clinicians would be able to submit a single measure via multiple mechanisms (QCDR and claims) and be scored on the data submission with the higher score.

  • Incremental implementation of MIPS: For 2019, the CMS proposed to increase the Performance Threshold to 30 points in 2019 from the previous 15 points. Clinicians will have to score above this threshold to be eligible to receive positive payment adjustments. The CMS also increased the eligibility for the $500 million bonus pool to 80 points.
  • Inclusions and Exclusions: The CMS proposed a new third criterion along with the two previous criteria to determine whether individual clinicians and groups are excluded from MIPS. Starting in Year 3, 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.

    For 2019, the CMS proposed to make it easier for facility-based clinicians by automatically having their MIPS quality and cost categories scores assigned based on their attributed facility’s Hospital Value-Based Purchasing (VBP) program.

    The CMS’ language around participation in cost measures for non-patient-facing MIPS eligible clinicians who have sufficient case volume, in accordance with the attribution methodology, will require further analysis to determine the impact on pathologists.
  • Application of payment adjustments: In order to implement the Bipartisan Budget Act of 2018, the CMS changed the application of MIPS payment adjustments, so that the adjustments will not apply to all items and services under Medicare Part B, but will now apply only to covered professional services paid under or based on the Physician Fee Schedule beginning with 2019. This clarifies the exclusion of CLFS revenue for purposes of this calculation.

Through the years, the CAP has advocated to reduce the quality reporting burden, and increase flexibility for pathologists in a way that recognizes and accounts for the value of the pathologist’s role in patient care. The CAP has actively worked with the CMS to demonstrate the need for more appropriate and alternate measures and activities for pathologists in order for them to more fully participate in MIPS.

Alternative Payment Models

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

To be considered an Advanced APM in 2019, the CMS is increasing the percentage of eligible clinicians that must use Certified EHR Technology from 50% to at least 75% of eligible clinicians in each APM entity. According to the CMS, this is to promote the “seamless and secure exchange of health information for clinicians and patients.” As in the MIPS track, the CMS is also clarifying their Advanced APM requirement for “MIPS-comparable quality measures,” and outcome measures. Both changes would take place starting January 1, 2020, and would require the measures either (1) be finalized on the MIPS final list of measures, (2) be endorsed by a consensus-based entity, or (3) otherwise determined by the CMS to be evidence-based, reliable, and valid.

Further, the CMS is proposing to maintain the 8% nominal amount standard for the Qualifying APM Participant through 2024. Finally, the CMS responded favorably to the CAP’s request by proposing increased flexibility for the All-Payer Combination Option and Other Payer Advanced APMs for non-Medicare payers to participate in the Quality Payment Program.

The CAP will be analyzing in detail the MIPS provisions in the coming weeks and will be submitting comments to the CMS by the deadline of September 10, 2018.

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.

STATLINE will provide updates on the 2019 Proposed QPP regulation and its impact on pathology. CAP members are encouraged to attend the July 24 webinar where CAP experts will review both proposed 2019 regulations and their impact on payment for pathology services.

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1 PM ET/ Noon CT

Register today.

The CAP will review the full details about the proposed rules in future editions of STATLINE. However, on July 24 at 1 pm ET, the CAP will offer a complimentary live webinar where CAP experts will review the proposed regulation changes that will impact payment for services and pathologists’ participation in the Merit-based Incentive Payment System or MIPS.

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. CAP Policy and Advocacy Vice President John H. Scott will moderate the webinar. The panel will also answer questions from attendees.

Learn and understand the practice and financial implications that these Medicare program changes will have on pathologists in 2019. Register Today.

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