Higher pay for fibrinolysins interpretation in ’19 fee schedule

The CMS did not agree with the CAP and RUC recommendation to increase payment for CPT code 85097 (bone marrow, smear interpretation) by increasing the work RVU for the service to 1.00 from its 0.94 value for 2018. Instead, the CMS is maintaining the current work RVU of 0.94 for 2019.

Overall, the CMS projected that changes in the fee schedule will result in a two percent decrease in Medicare allowed charges to pathology services next year. The decrease is largely due to final changes to practice expense RVUs after an extensive review of supply and equipment prices. In the payment for physician services, the practice expense RVUs include the costs associated with nonphysician or clinical labor time in addition to the costs of the supplies and equipment used to furnish the service.

The last time the CMS systematically reviewed prices to develop practice expense RVUs was 2004–2005. The Protecting Access to Medicare Act of 2014 authorized the CMS to use other sources to determine RVUs. For the recent effort, the CMS contracted with the firm StrategyGen to submit a report with pricing recommendations for 1,300 supplies and 750 equipment items used for direct practice expense units. The CMS accepted the recommendations and, starting in 2019, is phasing in the practice expense inputs over a four-year period.

After the CMS released its proposed rule in July, the CAP reviewed the StrategyGen pricing recommendations and noticed a number of new prices that appeared to be inaccurate by not reflecting either the proper product, quantity, or unit of measure for the service. Concerned about the accuracy of the prices, the CAP urged the CMS to postpone implementing StrategyGen’s recommendations so physician specialties can review and provide further comment on the inputs affecting practice expense RVUs. In response to the CAP’s concern and those of other physician specialty associations, the CMS disagreed that delaying implementation of the pricing inputs would lead to more accurate pricing. However, the CMS encouraged physicians to identify supply and equipment codes that will require additional research throughout the four-year transition. Additional information provided by the CAP to the CMS may result in updates to inputs to supply and equipment items. The CAP is working with the agency on prices for supplies that pathologists and laboratories use by, for example, submitting invoices for equipment.

In advocating for appropriate valuation, the CAP gathers information through the RUC’s physician work survey process. The surveys collect information about each of the components of physician work and provide for a comparison of that work with other pathology services and with other specialties’ services to develop a physician work RVU recommendation. The CAP’s RUC advisor presents the RUC survey data and recommendations to the RUC for consideration. The RUC submits its recommended values and other data to the CMS for use in the proposed physician fee schedule. The CMS can accept the recommendation, alter it, or reject it and value the service using its own analy­sis. The CAP advocates for adoption of the CAP-developed values in the final Medicare physician fee schedule.

Charles Fiegl is director of CAP advocacy communications, Washington, DC.