CMS Needs to Make Changes to Medicare PFS, ASCP Urges

Publication Date: Sep 28, 2021

On September 13, ASCP urged the Centers for Medicare and Medicaid Services (CMS) to make a series of changes to its Medicare Physician Fee Schedule (PFS) Proposed Rule for CY 2022. In a formal comment letter, one of two submitted to CMS, ASCP urged the Agency to change the rule to help appropriately reimburse pathology and laboratory services. As Medicare payment rates are often adopted by private payers, it is critical that Medicare provide appropriate reimbursement to ensure that pathology practices and clinical laboratories have the financial resources necessary for proper staffing and prompt, quality care.

In ASCP’s payment-focused comment letter, the Society raised concerns about Physician Self-Referral reforms, payment rates for a set of new pathology consult codes, updating PFS payment rates to reflect the labor costs (non-physician) associated with the technical component of pathology services, and others.

On the issue of self-referral, ASCP urged that anatomic pathology services no longer qualify as an exception to the Physician Self-Referral laws, which is intended to prevent physicians from profiting on the services they refer. This would help prevent referring physicians from urging sub-market pricing from their referrals so they can mark-up the service and profit on the service.

In addition, ASCP urged that CMS close a loophole in the Clinical Laboratory Improvement Amendments (CLIA) rules that allow technical component-only laboratories to operate outside of the CLIA high complexity regulations. ASCP argued this critical work must be performed and supervised as though the service were being performed in a full service, CLIA-certified high complexity laboratory, under the supervision and oversight of a qualified laboratory director and performed by laboratory personnel who meet CLIA’s high complexity personnel requirements.

In addition, ASCP advocated that CMS revise its payment plans for four new pathology consult codes. These new codes, CPT codes 80XX0, 80XX1, 80XX2, and 80XX3, replace 80500 and 80502. ASCP urged the Agency to accept the full recommendations from the AMA Relative Value Scale (RVS) Update Committee (RUC), which conducted a thorough re-examination of the cost inputs associated with these services.

In response to questions CMS posed about how it should pay for the use of innovative technologies for Medicare beneficiaries, ASCP urged CMS to ensure that digital pathology is adequately reimbursed and that laboratory services reimbursed under the Clinical Laboratory Fee Schedule, such as Multiple Analyte Algorithmic Analyses, be reimbursed so that the costs associated with the algorithms inherent in these services are covered. ASCP argued that current payment rates for these services diminishes the incentive to create novel technologies that can improve the standard of care. ASCP also urged CMS to make adjustments to its plans to update the PFS’s clinical labor wage inputs. ASCP raised concerns that the proposal could pose unsustainable cuts on some pathology subspecialties and should be fazed in over 5 years of more. For a copy of ASCP's comments, click here.

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For more information regarding ASCP's advocacy initiatives and policy positions, please contact ASCP's Center for Public Policy at (202) 408-1110.

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ASCP ePolicy News is supported by an unrestricted grant from Hologic.

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