Higher pay for fibrinolysins interpretation in ’19 fee schedule

Changes to practice expense result in overall decrease to pathology services

Charles Fiegl

December 2018—The CMS finalized its 2019 Medicare physician fee schedule and its response to the CAP’s recommendations to raise payment for fibrinolysins interpretation and reporting and to forgo a proposed decrease to the physician work value for blood smear interpretation.

The Centers for Medicare and Medicaid Services on Nov. 1 published the 2019 physician fee schedule. Services on the physician fee schedule are composed of three relative value units designated by the CMS: physician work, practice expense, and malpractice liability RVUs. Each RVU is separately valued and summed to equal the total RVU for each physician service on the fee schedule. The CAP advocates for the appropriate valuation of pathology services through its representation on the advisory committee of the AMA/Specialty Society Relative Value Scale Update Committee, known as RUC.

A July 2017 Advances in Anatomic Pathology article, “Current valuation of pathology service,” coauthored by Jonathan L. Myles, MD, who served previously as the CAP’s member on the RUC advisory committee and serves now on the CAP Board of Governors, explains how pathology services are valued and notes that the work RVU component represents a “physician’s time to perform the service, the technical skill and physical effort, the required mental effort, and judgement, as well as the stress due to potential risk to the patient” (Myles JL, et al. 24[4]:222–225).

View 2019 Medicare physician fee schedule

After the proposed 2019 Medicare physician fee schedule was released in July, the CAP urged the CMS to accept the CAP-developed physician work RVUs that the RUC had approved and submitted to the CMS. In addition, the CAP developed direct practice expense inputs for pathology services, which are the basis of global payments as well as payment for the technical component.

Previously, the Medicare program had identified as potentially misvalued the service for fibrinolysins or coagulopathy screen interpretation and report (CPT code 85390), which triggered a review of its physician work RVU. The RUC reviewed it and recommended an increase in payment. The CMS agreed with the recommended value, and the service will be paid at the national rate of $38.20 in 2019, an increase of 104 percent from $18.72 in 2018.

The CMS also finalized 2019 payment changes for new and revised fine needle aspiration biopsy services. This CPT code family includes fine needle aspiration biopsy without imaging guidance (CPT codes 10021 and 10004), with ultrasound guidance (CPT codes 10005 and 10006), as well as FNA biopsy codes that include other imaging modalities. For FNA biopsy services (CPT codes 10021, 10004–10006), the CMS also agreed with most of the valuation recommendations from the CAP and its coalition partners after a review of new and revised codes for the services. After a thorough review, the RUC recommended a work RVU of 1.20 for CPT code 10021 (fine needle aspiration biopsy, without imaging guidance; first lesion), a slight decrease from the 2018 work RVU of 1.27. However, the CMS disagreed with the RUC-recommended work RVU for CPT code 10021 and finalized a work RVU of 1.03 based on a direct crosswalk to CPT code 36440 (push transfusion, blood, two years or younger).

The CMS accepted and finalized RUC recommendations for work RVUs of 0.80 and 1.00 for new CPT codes 10004 (fine needle aspiration biopsy, without imaging guidance; each additional lesion) and 10006 (fine needle aspiration biopsy, including ultrasound guidance; each additional lesion), respectively. The service 10005 (fine needle aspiration biopsy, including ultrasound guidance; first lesion) will have a 2019 work RVU of 1.46; the RUC had recommended a 1.63 work RVU.

The CMS agreed in the final fee schedule with the CAP recommendation to maintain payment for CPT code 85060. After the CMS had proposed a decrease in July, the CAP defended the developed value and urged the CMS to adopt the RUC approved value. A number of variables should be considered in the evaluation of a blood smear when compared to others, the CAP said in its comments, including red blood cell count, size and morphology, platelet morphology and number, white blood cell morphology, and the presence of WBC precursors. The CMS accepted the current work RVU of 0.45.