Overview of Impact on Pathology Payment
On July 13, 2021, the Centers for Medicare & Medicaid Services (CMS) released its Medicare Physician Fee Schedule (PFS) Proposed Rule for CY 2022. The rule outlines the Agency’s proposed policy changes affecting Medicare payments under the PFS. The PFS pays for the services of physicians and other billing professionals in a variety of settings, including physician offices, hospitals, clinical laboratories, and others. Payment is also made to several types of suppliers for technical services, like clinical laboratories.
Estimated Impact on Reimbursement: During a recent American Medical Association (AMA) meeting, CMS clarified the financial impact of its PFS Proposed Rule on medical specialties. The Proposed Rule was initially estimated to reduce overall charges by pathologists by one percent and two percent for clinical laboratories. However, this impact does not take into account CMS’s proposed 3.75-percent reduction in the conversion factor. As a result, the AMA sent out to medical specialties a revised impact statement showing that for pathology and clinical laboratories, the AMA-estimated reduction in overall charges attributable to the Proposed Rule is 4.7 percent for pathologists and 5.9 percent for clinical laboratories. The impact of reduced charges on clinical labs is mitigated somewhat by the fact that clinical laboratories receive 83 percent of their direct Medicare revenues from the Clinical Laboratory Fee Schedule (CLFS). For an overview of proposed price changes to individual pathology CPT codes paid under the Medicare PFS, click
here.
New Pathology-specific Policy Changes: New for 2022 is the adoption of a series of new pathology consult codes: 80XX0-80XX32. These new codes replace CPT codes 80500 & 80502. The new codes were developed by the Pathology Coding Caucus (with ASCP’s support) as part of the American Medical Association’s Current Procedural Terminology (CPT) review process. 80500 and 805023 had been identified as potentially mis-valued.
In adopting the new codes, however, CMS has proposed a lower work RVU value (0.43) than had been recommended by the AMA/Specialty Society Relative Value Scale Update Committee (RUC), which recommended a value of 0.50. While the value CMS proposed for new code 80XX0 is 16 percent greater than that of retired code 80500, ASCP is concerned with CMS’s rational for the reduced work RVU value and plans to urge the Agency to adopt the full RUC recommendation when we submit formal comments on the Proposed Rule in September.
Laboratory specimen collection fees: CMS announced in its Proposed Rule that it plans to discontinue the laboratory specimen collection fees for COVID-19 tests when the public health emergency (PHE) ends. That said, the Agency announced it will be accepting comments about its policies for specimen collection fees and travel allowances—specifically for collecting specimens from homebound patients and inpatients—for consideration in future rulemaking.
Appropriate Use Criteria Program (AUC): CMs is also proposing to delay the initiation of the AUC payment penalty program to Jan. 1, 2023 or the Jan. 1 that follows the declared end of the public health emergency (PHE), whichever is later. Previously, the penalty was supposed to go into effect on Jan. 1, 2022, but CMS is proposing to delay it because of the impact of the PHE.
Overview of Medicare Shared Savings Program Changes
Under the Proposed Rule, CMS is expanding the reach of the QPP participation requirement, proposing that almost all pathologists will be required to participate in 2022. Pathologists will be able to satisfy QPP requirements and avoid penalties via participation in an
Advanced Alternative Payment Model (APM) or the
Merit-based Incentive Payment System. The performance incentives for CY 2022 alters overall Medicare Part B payments by +/- 9 percent.
CMS is proposing to set the performance threshold at 75 points, up from 60 points, while increasing the Exceptional Performance Threshold from 85 points to 89 points.
MIPS Value Pathways will go into effect in 2023, beginning with seven options. However, CMS is soliciting input on its plans to sunset the MIPS program in 2027.
Despite past statements and plans to sunset topped-out measures, all of the individual measures in pathology specialty measure remain. In addition, two new Improvement Activity measures have been proposed pertaining to the public health emergency and pandemic planning. The
first measure incentivizes clinical laboratories to develop preparedness plans to “maintain or expand patient access to healthcare service” while
the second incentivizes providers to develop plans to ensure they have adequate supplies of personnel protective equipment to safeguard healthcare professionals.
For Accountable Care Organizations (ACOs), CMS is proposing to extend the transition period for the reporting of electronic clinical quality measure/Merit Based Incentive Payment System (MIPS) all payer quality measures via the Alternative Payment Model Performance Pathway. Under the Proposed Rule, CMS would allow collection of quality data through the CMS Web Interface for an additional two years, 2022 and 2023.
Due to mounting concerns that participation in the QPP is becoming more complex and burdensome, ASCP will, as we have regularly done so in the past, urge CMS to reduce the burden of compliance with the Proposed Rule. ASCP is still in the process of reviewing the Proposed Rule and will be submitting formal comments prior to the rule’s September 7 deadline.
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