Read the latest ASCP policy news from Washington, DC.
ASCP ANALYSIS OF PAYMENT PROVISIONS IN THE PROPOSED 2018 MEDICARE PHYSICIAN FEE SCHEDULE
On July 13, 2017, the Centers for Medicare & Medicaid Services (CMS) released its proposed rule to update payment policies, payment rates, and quality provisions for services furnished under the Medicare Physician Fee Schedule (PFS) on or after January 1, 2018. The calendar year (CY) 2018 PFS proposed rule is one of several recent proposed rules that reflect a broader Administration-wide strategy to create a healthcare system that results in better accessibility, quality, affordability, empowerment, and innovation. This article focuses only on the payment policies affecting pathology services reimbursed by the Medicare PFS. ASCP will report on other issues dealt with in the proposed rule, such as the quality payment program created by the Medicare Access and CHIP Reauthorization Act (MACRA) and proposed policies affecting the Clinical Laboratory Fee Schedule (CLFS), in the August issue of ePolicy.
Overall Payment Update and Misvalued Code Target
The overall update to payments (for all provider specialties) under the PFS based on the proposed CY 2018 rates would be +0.31 percent. This change reflects the +0.50 percent update established under MACRA and a reduction of 0.19 percent due to the misvalued code target recapture amount required under the Achieving a Better Life Experience (ABLE) Act of 2014. That said, according to CMS’s proposed rule, overall payment for pathologists is expected to decline by one percent next year whereas payment rates for independent clinical laboratories would fall by two percent. These projections, however, are averages, and how the proposed 2018 payment rates will affect pathologists and laboratories will ultimately depend on the mix of pathology services each provides. ASCP has developed this initial analysis of the proposed payment rates to provide more clarity on how the proposed payment rates will affect pathologists and independent laboratories.
Overview of Proposed Pathology Payment Rates for 2018
Overall, most of the proposed changes in reimbursement are relatively low. Of the roughly 230 CPT codes used by pathologists, only 24 saw a change in reimbursement of more than 10 percent. Of these 24 codes, 13 were cuts and 11 were payment increases. Of the codes experiencing cuts this year, many are frequently performed services that have been the target of cuts in recent years. These codes were largely targeted as part of CMS’s misvalued code initiative, utilizing a high expenditure screen for services with more than $10 million in allowed charges.
For example, CMS is targeting G0416 (Prostate Biopsy, any method) yet again for cuts, reducing payment from $490.93 to $434.40, a 12 percent cut. The Flow Cytometry family of codes also saw cuts, with 88185 (Flow Cytometry, TC add-on) proposed for a 19 percent cut, falling from $37.68 to $31.59. CPT 88187 (Flow Cytometry, 2-8) was reduced to $48.22 from $59.21, also a 19 percent cut, and CPT 88188 (Flow Cytometry, 9-15) was reduced 12 percent to $66.22 from $75.36.
Several CPT codes for the professional component of tumor immunohistochemistry procedures saw decreases as well, with CPT 88360-26 dropping from $57.42 to $46.78, down 19 percent, and CPT 88361-26 also dropping 19 percent, from $61.01 to $49.67. Several pathology consultation codes also saw their reimbursement rate reduced. CPT code 88333-TC was cut from $29.07 to $23.39, a 20 percent reduction, while CPT 88334-TC declined to $16.56 from $19.74, a 16 percent cut. CPT 88323-TC (Microslide consultation) was hit with a 19 percent cut, dropping from $41.27 to $33.47.
How CMS Determines Payment Rates
CMS payment rates are based on CMS’s determination of the relative resources typically used to furnish a service. Every year, CMS reviews the resource inputs for several hundred codes under the annual process referred to as the potentially misvalued code initiative. Recommendations from the American Medical Association Relative Value Scale Update Committee (RUC) are used as part of this work. For CY 2018, CMS is proposing the values for individual services that generally reflect the expert recommendations from the RUC without as many refinements as CMS has proposed in recent years.
Among the codes used by pathologists experiencing the biggest proposed reimbursement increases are CPT 88125-TC (Forensic Cytopathology), CPT 88182-TC (Cell marker study), CPT 88314-TC (Histochemical stain add-on), and CPT code 36522 (Photopheresis). CPT code 88125-TC (Forensic Cytopathology) increased from $7.90 to $12.24, a 55 percent increase. The professional component for this service increased 11 percent to $14.77. This brings the global payment for the service to $27.00, up 27 percent from $21.17. CPT code 88182-TC (Cell marker study) increased to $92.50 from $82.54, a 12 percent change. CPT 88314-TC (Histochemical stain add-on) increased from $55.98 to $62.26, an 11 percent increase. CMS also proposed to increase payment for CPT code 36522 (Photopheresis) from $1445.17 to $2506, a 73 percent increase. CMS is proposing a new HCPCS code, 382X3, for bone marrow biopsy and aspirations and eliminating its G code, G0364. Reimbursement for the code will be set at $173.47, similar to the payment for CPT 38220 (bone marrow aspiration) and 38221 (bone marrow biopsy). Please note these are only proposed changes in payment rates. Final payment rates will be set in the final rule, which will come out later this year.
For more information about changes in specific CPT codes, see ASCP’s comparison chart
of the 2018 proposed rates with the 2017 Final Rates.
ASCP is still in the process of reviewing the rule for its impact on the pathology and laboratory community. ASCP will be responding to CMS about the rule with the intent of relaying the community’s concern with the policy proposals outlined in the rule.
CONTACT YOUR MEMBERS OF CONGRESS, CMS’ PLANS COULD AFFECT PATIENT ACCESS TO LAB SERVICES
The laboratory community needs your help to delay the Centers for Medicare and Medicaid Services (CMS) from implementing new payment rates for the Medicare Clinical Laboratory Fee Schedule (CLFS).
In 2014, Congress passed the Protecting Access to Medicare Act (PAMA) to base Medicare CLFS reimbursement rates on laboratory-reported private market rates. Unfortunately, current Medicare rules exclude 95 percent of clinical laboratories, including most physician office and hospital laboratories, from reporting their private market rates. ASCP is concerned that many of the CLFS payment rates may be underpriced relative to the true market rate.
ASCP is asking you to contact your Members of Congress and ask them to urge CMS to delay PAMA implementation until CMS can develop CLFS rates that factor in the full laboratory market and are truly market-based. Learn more and contact your Members of Congress here.
For more information regarding ASCP's
advocacy initiatives and policy positions, please contact ASCP's Center for Public Policy at (202-347-4450).
ePolicy News is supported by
an unrestricted grant from Hologic.