The early July release of the Medicare Physician Fee Schedule (MPFS) includes a few proposed changes, but overall a possible positive impact on pathology group and laboratory’s bottom lines. Most notable is a proposed increase to most commonly used CPT codes ranging between 1 and 5 percent. Overall, independent clinical laboratories would see an increase of around 3 percent and hospital based pathology groups billing professionally may expect to see around a 1 percent increase. In addition to the increases in reimbursement, proposed changes specific to pathology include the following:
New PQRS Measures
Lung cancer biopsy/cytology specimen: Pathology reports based on biopsy and/or cytology specimens with a diagnosis of non-small cell lung cancer classified into specific histologic type or classified as NSCLC-NOS with an explanation included in the pathology report
Lung cancer resection specimen: Pathology reports based on resection specimens with a diagnosis of primary lung carcinoma that include the pT category, pN category and for non-small cell lung cancer, histologic type.
Melanoma specimen: Pathology reports for primary malignant cutaneous melanoma that include the pT category and a statement on thickness and ulceration and for pT1, mitotic rate.
It is important to remember that beginning in 2015, failure to participate in the PQRS program will result in a penalty, rather than the bonus received for participating in previous years.
Local Coverage Determinations
Earlier this year, the Protecting Access to Medicare Act (PAMA) was enacted. As part of this policy, MACs are required to issue coverage policies with respect to clinical diagnostic laboratory tests in accordance with the process for making local coverage determinations (LCDs). The goal is to allow enough time for notification of stakeholders and public dialogue with the need to finalize a large number of LCDs in a timely manner to expedite beneficiary access to covered clinical laboratory tests. CMS noted the Molecular Diagnostic Services Program launched by Palmetto GBA in 2011, stating that the agency believes the pilot program’s “design and some of the lessons learned from the pilot can be applied to all clinical laboratory tests.” CMS also went on to note the importance of maintaining key aspects to the current process, such as allowing public comment on draft LCDs and requiring MAC responses to public comments.
Prostate Biopsy Codes
2014 saw changes to how we code prostate biopsies for CMS patients. The change included “G” codes G0416 (10-20 specimen), G0417 (21-40 specimen), G0418 (41-60 specimen) and G0419 (more than 60 specimen). For 2015 CMS is proposing the use of only code G0416, regardless of the number of specimens. Further, CMS is citing the G0416 as a potentially misvalued code ($651.26 national reimbursement rate) and is seeking comment on appropriate work RVUs, work time, and direct practice expense (PE) inputs.
Fee Rate Transparency
CMS has proposed to improve transparency in the Professional Fee Schedule (PFS) rate setting by implementing a process by 2016 to allow all misvalued code revisions to go through a notice and comment rulemaking period before adoption. In the 2014 final rule, we saw major changes to RVU values, which were not easily apparent upon the review of the 2014 proposed rule last July. As part of this effort at better transparency, CMS proposes to make all changes to RVUs be made available in the proposed rule in 2016 for codes that CMS receives Relative Value Scale Update Committee (RUC) recommendations on or by Jan. 15 of the previous year. Also, should the RUC not provide recommendations in time, CMS will create “G” codes, which will effectively delay any cuts to reimbursement by one year.
Linking of Pathology Payments to HOPPS
As in 2013, CMS once again discussed a proposal to link payments made under the Professional Fee Schedule (PFS) to those made in hospital outpatient settings. According to this proposal, CMS would compare all payment rates for anatomic pathology (AP) services under the PFS and the Hospital Outpatient Prospective Payment System (HOPPS) and set reimbursement according to whichever rate is lower. This was not finalized last year and CMS said it would take more time to consider comments and develop an alternate proposal. According to CMS, the Protecting Access to Medicare Act (PAMA) provides expanded legal authority for the agency to review payments based on differences across sites of service. CMS will seek comments on utilizing hospital cost data for use in valuing the practice expense payment for physician services.
These are what can be considered the highlights of the 2015 CMS proposed rule. APS will monitor the outcome of the now open comment period and keep you abreast of any foreseen or finalized outcomes. If you have any questions about this information, please contact your Practice Manager.