2015 Medicare Payment Changes

How the Final Physician Fee Schedule Rule Impacts Pathologists PRESENTED BY

Jonathan L. Myles, MD, FCAP

DATE

November 5, 2014 Mark S. Synovec, MD, FCAP John H. Scott, Vice President, CAP Advocacy and Policy

Agenda

•

Welcome

–

Our Presenters

–

CAP Advocacy and Policy

•

Payment for Pathology Services

•

Quality Reporting Initiatives

•

Local Coverage Determinations

•

Questions

© 2014 College of American Pathologists. All rights reserved. 2

Our Presenters

Jonathan L. Myles, MD, FCAP

•

Chair, CAP Economic Affairs Committee

•

Pathology Advisor to the AMA RUC

© 2014 College of American Pathologists. All rights reserved. 3

Our Presenters

Mark S. Synovec, MD, FCAP

•

Advisor, Council on Government and Professional Affairs

•

Liaison, AMA House of Delegates

•

Member AMA CPT Editorial Panel

© 2014 College of American Pathologists. All rights reserved. 4

Payment for Pathology Services

•

Impact on services targeted by CMS as misvalued

–

Immunohistochemistry

–

Prostate Biopsy G-code

–

In Situ Hybridization Services (FISH)

–

Comparing Physician Payment to Hospital Data

© 2014 College of American Pathologists. All rights reserved. 5

Payment for Pathology Services

© 2014 College of American Pathologists. All rights reserved. 6

Immunohistochemistry

•

CMS created IHC G-codes for 2014

•

CAP advocated for alternative

–

Proposed changes to CPT codes

–

CAP developed code change proposals

–

Led valuation efforts aimed at addressing CMS’ concerns with overpayment in order to protect reimbursement

•

CMS accepted the CAP’s code recommendations for IHC

•

CMS lowered value for add-on code

© 2014 College of American Pathologists. All rights reserved. 7

Immunohistochemistry

88342

(Immunohistochemistry or immunocytochemistry, per specimen; initial single antibody stain procedure) (For quantitative or semiquantitative immunohistochemistry, see 88360, 88361) (88343 has been deleted. For multiplex antibody stain procedure, use 88344) 8

Immunohistochemistry

88341

(Immunohistochemistry or immunocytochemistry, per specimen; each additional single antibody stain procedure (List separately in addition to code for primary procedure) (Use 88341 in conjunction with 88342) (For multiplex antibody stain procedure, use 88344) 9

Immunohistochemistry

88344

(Immunohistochemistry or immunocytochemistry, per specimen; each multiplex antibody stain procedure) (Do not use more than one unit of 88341, 88342, 88344 for each separately identifiable antibody per specimen) (Do not report 88341, 88342, 88344 in conjunction with 88360, 88361 unless each procedure is for a different antibody) 10

Immunohistochemistry

(When multiple separately identifiable antibodies are applied to the same specimen [ie, multiplex antibody stain procedure], use one unit of 88344) (When multiple antibodies are applied to the same slide that are not separately identifiable, [eg, antibody cocktails], use 88342, unless an additional separately identifiable antibody is also used, then use 88344) 11

Immunohistochemistry

2013 88342 2014 G0461 (first) 2014 G0462 (additional) 2015 88342 (initial) 2015 88341 (additional) 2015 88344 (multiplex) Physician Work RVU Global Payment PC Payment TC Payment

.85

.60

.24

.70

.42

.77

$115.34

$88.48

$68.42

$90.58

$67.31

$117.07

$42.19

$30.81

$12.54

$36.52

$21.84

$40.10

$73.15

$57.67

$55.88

$54.06

$45.47

$76.97

12

Prostate Biopsy G-code

•

CMS finalized its proposal for 2015

•

Use G0416 to report prostate biopsy services, regardless of specimens, in 2015

–

Applies to all prostate biopsy specimens 1-9

–

Other prostate G-codes and 88305 no longer valid in 2015

•

CAP had urged the CMS to withdraw the proposal

© 2014 College of American Pathologists. All rights reserved. 13

Prostate Biopsy G-code

Prostate Biopsy G-code

•

2015 payment is the same as 2014

•

CMS believes the service is misvalued

–

Wants the service to be revalued for 2016

•

Now, CAP will lead RUC review of the service G0416 88305 G0416/88305

© 2014 College of American Pathologists. All rights reserved.

2015 Global

$649.08 $73.03 8.89

2015 26

$182.59 $39.02 4.68

2015 TC

$466.49 $34.01 13.72

14

In Situ Hybridization Services (FISH)

CAP advocated for CPT code changes to address CMS’ payment concerns for the service

–

FISH codes have been under review for several years

–

National Correct Coding Initiative (NCCI) manual included reporting limits

–

Sought to avoid CMS creating more G-codes

© 2014 College of American Pathologists. All rights reserved. 15

National Correct Coding Initiative (NCCI)

NCCI Policy Manual

•

Separate process which impacts payment for physician services

•

Last year’s manual limited payment for FISH services

•

December release anticipated

•

CAP will review and comment prior to January 1 effective date

16

National Correct Coding Initiative (NCCI)

Medically Unlikely Edits, NCCI Coding Edits

•

Code edit pairs and limitations set by CMS through NCCI

•

CAP reviews draft edits and provides feedback to CMS

•

If published, edits will appear on CMS website

•

December release anticipated

17

In Situ Hybridization Services (FISH)

88365

In situ hybridization (eg, FISH), per specimen; initial single probe stain procedure

88364

In situ hybridization (eg, FISH), per specimen; each additional single probe stain procedure (List separately in addition to code for primary procedure) (Use 88364 in conjunction with 88365) © 2014 College of American Pathologists. All rights reserved. 18

In Situ Hybridization Services (FISH)

88366

In situ hybridization (eg, FISH), per specimen; each multiplex probe stain procedure (Do not report 88365, 88366 in conjunction with 88367, 88368, 88374, 88377 for the same probe)

88367

Morphometric analysis, in situ hybridization (quantitative or semi-quantitative), using computer assisted technology, per specimen; initial single probe stain procedure © 2014 College of American Pathologists. All rights reserved. 19

In Situ Hybridization Services (FISH)

88373

Morphometric analysis, in situ hybridization (quantitative or semi-quantitative), using computer assisted technology, per specimen; each additional single probe stain procedure (List separately in addition to code for primary procedure) (Use 88373 in conjunction with 88367) © 2014 College of American Pathologists. All rights reserved. 20

In Situ Hybridization Services (FISH)

88374

Morphometric analysis, in situ hybridization (quantitative or semi-quantitative), using computer assisted technology, per specimen; each multiplex probe stain procedure (Do not report 88367, 88374 in conjunction with 88365, 88366, 88368, 88377 for the same probe) 21

In Situ Hybridization Services (FISH)

88368

Morphometric analysis, in situ hybridization (quantitative or semi-quantitative), manual, per specimen; initial single probe stain procedure

88369

Morphometric analysis, in situ hybridization (quantitative or semi-quantitative), manual, per specimen; each additional single probe stain procedure (List separately in addition to code for primary procedure) (Use 88369 in conjunction with 88368) 22

In Situ Hybridization Services (FISH)

88377

Morphometric analysis, in situ hybridization (quantitative or semi-quantitative), manual, per specimen; each multiplex probe stain procedure (Do not report 88368 or 88377 in conjunction with 88365, 88366, 88367, 88374 for the same probe) (For morphometric in situ hybridization evaluation of urinary tract cytologic specimens, see 88120, 88121) 23

In Situ Hybridization Services (FISH)

2013 88365 2014 88365 2015 88365 (initial) 2015 88364 (additional) 2015 88366 (multiplex) Physician Work RVU Qualitative Global Payment PC Payment TC Payment

1.20

1.20

.88

.53

1.24

$178.62

$177.32

$157.17

$97.38

$150.01

$58.18

$60.18

$44.75

$27.21

$63.73

$120.44

$117.14

$112.42

$70.17

$86.28

© 2014 College of American Pathologists. All rights reserved. 24

In Situ Hybridization Services (FISH)

2013 88367 2014 88367 2015 88367 (initial) 2015 88373 (additional) 2015 88374 (multiplex) Quantitative, Computer Assisted Physician Work RVU Global Payment PC Payment

1.30

1.30

.73

.43

$258.23

$255.77

$107.40

$60.15

$59.88

$62.69

$35.44

$21.12

TC Payment

$198.35

$193.08

$71.96

$39.02

.93

$205.14

$45.11

$160.03

© 2014 College of American Pathologists. All rights reserved. 25

In Situ Hybridization Services (FISH)

2013 88368 2014 88368 2015 88368 (initial) 2015 88369 (additional) 2015 88377 (multiplex) Quantitative, Manual Assisted Physician Work RVU Global Payment PC Payment TC Payment

1.40

1.40

.88

.53

$232.04

$232.49

$108.84

$73.75

$61.58

$64.84

$41.17

$25.06

$170.46

$167.65

$67.66

$48.69

1.40

$214.45

$65.52

$148.93

© 2014 College of American Pathologists. All rights reserved. 26

CMS Rejection of Direct Practice Expense Cost Inputs

•

TC and Global fees include direct practice expense costs for medical supplies, equipment and clinical labor

•

CMS cut or reduced key practice expense cost

–

Supply items rejected for FISH codes

–

Incorrect lower cost supplies substituted for IHC

–

Clinical staff time reduced for microdissection

•

CAP is advocating to restore cost items reduced or deleted by CMS to improve payment rates

© 2014 College of American Pathologists. All rights reserved.

Comparing Physician Payment to Hospital Data

•

Code families for 22 services reviewed to prevent use of hospital data for setting technical and global payments

•

For 2015, CMS did not take action on practice expense recommendations from the RUC associated with 22 pathology code families.

•

CMS Response: Continue to review use of other sources such as hospital cost data to review code values

© 2014 College of American Pathologists. All rights reserved. 28

Payment for Pathology Services

Optical Endomicroscopy – Interpretation

•

88375

•

CMS reversed its 2014 decision not to pay separately on the fee schedule and implemented Medicare payment based on CAP request .

© 2014 College of American Pathologists. All rights reserved. 29

Payment for Pathology Services

88375

Optical endomicroscopic image(s), interpretation and report, real-time or referred, each endoscopic session

(Do not report 88375 in conjunction with 43206 or 43252) Year 88375 Physician Work RVU Global Payment 2014

I - Inactive for Medicare I - Inactive for Medicare

2015

© 2014 College of American Pathologists. All rights reserved. .91

$46.54

30

Payment for Pathology Services

Microdissection

•

88380 and 88381

•

CMS accepted RUC-approved values developed by CAP

© 2014 College of American Pathologists. All rights reserved. 31

Payment for Pathology Services

88380

Microdissection (ie, sample preparation of microscopically identified target); laser capture

Year Physician Work RVU 88380 Global Payment PC Payment TC Payment 2014

1.56

2015

© 2014 College of American Pathologists. All rights reserved. 1.14

$190.58

$132.82

$80.24

$110.33

$76.26

$56.57

32

Payment for Pathology Services

88381

Microdissection (ie, sample preparation of microscopically identified target); manual (Do not report 88380 in conjunction with 88381)

Year Physician Work RVU 88381 Global Payment PC Payment TC Payment 2014

1.18

$160.84

$55.17

$105.68

2015

© 2014 College of American Pathologists. All rights reserved. .53

$124.59

$26.13

$98.45

33

Payment for Pathology Services

Cytopathology

•

CMS identified 88108 as potentially misvalued

•

CMS reviewed values for cytopathology service 88112 – and questions 88108 Flow cytometry

•

CMS identified TC add-on code as potentially overvalued

•

Requested review for 2016 payment change

© 2014 College of American Pathologists. All rights reserved. 34

Quality Reporting Initiatives

•

Physician Quality Reporting System

•

Physician Value-Based Modifier (VBM)

© 2014 College of American Pathologists. All rights reserved. 35

Physician Quality Reporting System

• The College is pleased that the CMS included three new pathology measures in the 2015 PQRS. • The measures are: –

Lung cancer reporting (biopsy/cytology specimens)

–

Lung cancer reporting (resection specimens)

–

Melanoma reporting

•

Register for the CAP’s December 2 PQRS Webinar

© 2014 College of American Pathologists. All rights reserved. 36

Physician Value-Based Modifier (VBM)

•

VBM will apply to all physicians in 2017

•

2015 PQRS will affect 2017 PQRS, VBM penalties

–

- 4% VBM penalty for physicians in groups 10 or more

–

- 2% VBM penalty for solo physicians, groups 2-9

–

Separate -2% penalty under PQRS program

•

Successful PQRS participation in 2015 can stop the 2017 penalties

© 2014 College of American Pathologists. All rights reserved. 37

LCD Process Changes

•

CMS proposed several Medicare Local Coverage Determination process changes

–

Expand Palmetto’s MolDX program

–

Shorten public comment period to 30 days from 45 days

–

Limited opportunities to suggest improvements to draft LCDs

•

CAP vigorously opposed the CMS’ proposal

•

CMS stated it would not move forward, but it would explore rulemaking on this issue in the future

© 2014 College of American Pathologists. All rights reserved. 38

Resources

•

CAP.org

•

2015 Policy Meeting

–

May 4-6, 2015, Washington, DC

•

STATLINE

© 2014 College of American Pathologists. All rights reserved. 39