cap.org v. # cms issues rule on medicare payment cuts in 2014, other significant developments...

cap.org v. #

CMS Issues Rule on Medicare Payment Cuts in 2014, Other Significant DevelopmentsJonathan Myles, MD, FCAP, Chair, Economic Affairs Committee Kathryn T. Knight, MD, FCAP, Chair, Federal and State Affairs Committee John Scott, Vice President of Advocacy, Moderator

December 4, 2013

Six Key Issues

• Anatomic Pathology Code Revaluations

• Immunohistochemistry: 88342 (PC & TC)

• Capping Payment Rates in the PFS at Hospital Outpatient APC Rates

• Changes to Medicare’s Hospital Outpatient Prospective Payment System

• Physician Quality Reporting System (PQRS)

• Clinical Laboratory Fee Schedule (CLFS)

• SGR and Self Referral

© 2013 College of American Pathologists. All rights reserved. 2

2014 Anatomic Pathology Code Revaluations

• Immunohistochemistry: 88342 (PC & TC) o CMS rejected the CAP’s proposal

o Two new G codes established

o Changes for the new G codes compared to current CPT code 88342:


CPT Code Modifier

88342 2013 Total

Payment

2014 Total

Payment

Total % Change

from 2013 88342

G0461

$115.34 $88.04 -24%

G0461 TC $73.15 $57.39 -22%

G0461 26 $42.19 $30.65 -27%

G0462

$115.34 $68.08 -41%

G0462 TC $73.15 $55.61 -24%

G0462 26 $42.19 $12.48 -70%

• Enhanced Cytology Services: 88112 (PC & TC) o 2014 Reductions

• In situ hybridization services: 88365, 88367 and 88368 (PC & TC)o Action deferred on revaluation for 2014 but 2015 changes

anticipated

o Limiting NCCI edits announced for 2014

2014 Anatomic Pathology Code Revaluations (cont.)


CPT Code Modifier

2013 Total

Payment

2014 Total

Payment

Total % Change

from 2013

88112

$109.55 $62.73 -43%

88112 26 $58.18 $28.16 -52%

88112 TC $51.37 $34.58 -33%

• 88305 TCo Additional data review requested in 2013

o CAP’s input resulted in no new cuts for 2014

• Prostate Biopsieso New restrictions on billing prostate biopsies specimens

o G codes now required for 10 or more specimens

• Optical Endomicroscopyo No new payment for unique pathology services

o Existing codes suggested to bill for this service

2014 Anatomic Pathology Code Revaluations (cont.)


• Change in Medicare Rates for other Top Volume Codes

High-Volume Pathology Services


HCPCS Mod Description2013 Total Payment

2014 Total Payment

Total % Change

88305 Tissue exam by pathologist $70.09 $70.22 0%

88305 26 Tissue exam by pathologist $36.74 $38.14 4%

88305 TC Tissue exam by pathologist $33.34 $32.08 -4%

88185 Flowcytometry/tc add-on $54.10 $53.47 -1%

88313 Special stains group 2 $67.71 $65.59 -3%

88313 26 Special stains group 2 $11.91 $12.12 2%

88313 TC Special stains group 2 $55.80 $53.47 -4%

88312 26 Special stains group 1 $26.54 $27.45 3%

88312 TC Special stains group 1 $71.11 $66.66 -6%

88312 Special stains group 1 $97.65 $94.10 -4%



88304 Tissue exam by pathologist $44.57 $43.13 -3%

84165 26 Protein e-phoresis serum $20.07 $19.25 -4%


88307 Tissue exam by pathologist $297.36 $286.94 -4%


• Background: o CAP opposed this policy that would have reduced the TC and

global payment of 39 pathology codes

• Outcomes:o CMS halted its plan for 2014

o Agency will revise and reissue a proposal in the future

o CMS remains committed to underlying payment policy

• Next Steps: o The CAP will consult with our coalition partners and

Congressional supporters to prevent future implementation

Capping Payment Rates in the PFS to Hospital Outpatient APC Rates


• Background: o This bundling proposal was a separate rule from the 2014 PFS

Rule and was released as part of the Hospital Outpatient Rule

• Outcomes:o For 2014 all clinical diagnostic laboratory tests (other than

molecular pathology) performed on hospital outpatients are “bundled” into payment for primary hospital outpatient procedures.

• Next Steps: o The CAP is continuing to analyze the impact of physician

pathology services provided to hospital outpatients

Changes to Medicare’s Hospital Outpatient Prospective Payment System


• Anatomic Pathology and Bundled Paymentso CMS will bundle certain “add on” codes with the initial

procedure code

Changes to Medicare’s Hospital Outpatient Prospective Payment System (cont.)


88177 Cytp fna eval ea addl 88185 Flowcytometry/tc add-on 88311 Decalcify tissue 88314 Histochemical stains add-on 88332 Path consult intraop addl

88334 Intraop cyto path consult 2 88388 Tiss ex molecul study add-on

• Outcomes:o CMS did not accept CAP’s three new pathology measures

o CMS will allow pathologists to qualify for 2014 incentives by reporting on the existing five measures by either claims or registry

• Next Steps: o The CAP is working with Congress on the SGR to create

flexibility for clinical practice improvement activities for pathologists to avoid PQRS penalties

o The CAP is meeting with CMS to gain a better understanding on the PQRS measures and will share what we learn in a future webinar

Physician Quality Reporting System (PQRS)


• Background: o CMS has long expressed concern that CLFS revaluation is

needed

o Last June the OIG concluded that Medicare paid 18-30 percent more than other insurers for 20 high-volume lab tests

• Outcomes:o CMS created a new process to revalue CLFS payment amounts

o Reductions to CLFS fees anticipated beginning in 2015 and continuing for five years

• Next Steps: o CAP will focus on influencing the revaluation process

Clinical Laboratory Fee Schedule (CLFS)


SGR and Self-Referral

• SGRo House Energy and Commerce Committee passed SGR reform

bill

o Senate Finance Committee marking up legislation next week

o No current proposal includes a method to pay for reform

o Congress is considering a short-term patch

o The CAP is working to attach our issues to any SGR legislation

• Self-Referralo Remains a politically charged issue

o The CAP believes now is the time to make a major push


Questions?


cap.org v. # cms issues rule on medicare payment cuts in 2014, other significant developments...

Documents

o changes

o agency

pc tc o cms

future o cms

pc tc o action

caps proposal o

o caps input

tctissue exam