Transcript 88342 (PC & TC) - College of American Pathologists

CMS Issues Rule on Medicare Payment Cuts in
2014, Other Significant Developments
Jonathan 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
cap.org
v. #
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.
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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
G0461
88342
2013
Total
Payment
2014
Total
Payment
Total %
Change
from 2013
88342
$115.34
$88.04
-24%
G0461
TC
$73.15
$57.39
-22%
G0461
26
$42.19
$30.65
-27%
$115.34
$68.08
-41%
G0462
G0462
TC
$73.15
$55.61
-24%
G0462
26
$42.19
$12.48
-70%
© 2013 College of American Pathologists. All rights reserved.
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2014 Anatomic Pathology Code Revaluations (cont.)
• Enhanced Cytology Services: 88112 (PC & TC)
o 2014 Reductions
CPT
Code
Modifier
88112
2013
Total
Payment
2014
Total
Payment
Total %
Change
from 2013
$109.55
$62.73
-43%
88112
26
$58.18
$28.16
-52%
88112
TC
$51.37
$34.58
-33%
• 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
© 2013 College of American Pathologists. All rights reserved.
4
2014 Anatomic Pathology Code Revaluations (cont.)
• 88305 TC
o Additional data review requested in 2013
o CAP’s input resulted in no new cuts for 2014
• Prostate Biopsies
o New restrictions on billing prostate biopsies specimens
o G codes now required for 10 or more specimens
• Optical Endomicroscopy
o No new payment for unique pathology services
o Existing codes suggested to bill for this service
© 2013 College of American Pathologists. All rights reserved.
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High-Volume Pathology Services
• Change in Medicare Rates for other Top Volume Codes
HCPCS
Mod
88305
Description
2013 Total
Payment
2014 Total Payment Total % Change
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%
Special stains group 1
$97.65
$94.10
-4%
88312
88304
26
Tissue exam by pathologist
$11.23
$11.41
2%
88304
TC
Tissue exam by pathologist
$33.34
$31.72
-5%
Tissue exam by pathologist
$44.57
$43.13
-3%
88304
84165
26
Protein e-phoresis serum
$20.07
$19.25
-4%
88307
26
Tissue exam by pathologist
$82.00
$83.76
2%
Tissue exam by pathologist
$297.36
$286.94
-4%
Tissue exam by pathologist
$215.37
$203.17
-6%
88307
88307
TC
© 2013 College of American Pathologists. All rights reserved.
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Capping Payment Rates in the PFS to Hospital
Outpatient APC Rates
• 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
© 2013 College of American Pathologists. All rights reserved.
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Changes to Medicare’s Hospital Outpatient
Prospective Payment System
• 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
© 2013 College of American Pathologists. All rights reserved.
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Changes to Medicare’s Hospital Outpatient
Prospective Payment System (cont.)
• Anatomic Pathology and Bundled Payments
o CMS will bundle certain “add on” codes with the initial procedure
code
88177
88185
88311
88314
88332
88334
88388
Cytp fna eval ea addl
Flowcytometry/tc add-on
Decalcify tissue
Histochemical stains add-on
Path consult intraop addl
Intraop cyto path consult 2
Tiss ex molecul study add-on
© 2013 College of American Pathologists. All rights reserved.
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Physician Quality Reporting System (PQRS)
• 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
© 2013 College of American Pathologists. All rights reserved.
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Clinical Laboratory Fee Schedule (CLFS)
• 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
© 2013 College of American Pathologists. All rights reserved.
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SGR and Self-Referral
• SGR
o 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-Referral
o Remains a politically charged issue
o The CAP believes now is the time to make a major push
© 2013 College of American Pathologists. All rights reserved.
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Questions?
© 2013 College of American Pathologists. All rights reserved.
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