Pay is up in Medicare proposal, but final picture unknown

“It’s likely that in the final rule we’ll see some decrease in the technical component, as well as global payment, for prostate services in G0416,” Dr. Myles said. “Also, CMS can make adjustments to any of the final codes we talked about.”

Another CAP leader, George F. Kwass, MD, echoed during the webinar Dr. Myles’ note of caution.

“We have to remember that one big piece of this puzzle has not as yet shown itself, and that’s the prostate bundle code—the G-code 0416 that we anticipate in the final rule,” said Dr. Kwass, chair of the CAP Council on Government and Professional Affairs. “Whether payment for that will go up, down, or stay the same remains a question which we don’t know the answer to, and which we can’t predict at the moment.”

As part of its ongoing effort to cut costs by reconsidering what it considers misvalued codes, the CMS proposed re-evaluating the following codes: 10022 (FNA w/image); 36516 (apheresis selective); 88160 (cytopath smear other source); 88161 (cytopath smear other source); 88162 (cytopath smear other source); 88185 (flowcytometry/tc add-on); 88189 (flowcytometry/read 16&>); 88321 (microslide consultation); 88360 (tumor immunohistochem/manual); 88361 (tumor immunohistochem/computl).

Also, payment for two flow cytometry-related codes, 88184 and 88185, is targeted for 38 and 69 percent cuts, respectively, phased in over the next two years. The CMS judged that the cost of performing these tests has fallen and that is why it has proposed cutting the pay so dramatically. Dr. Myles said the CAP will comment on this issue specifically “to get some of that back” and explain to the agency why, for example, a computer is needed in the room to run flow cytometry tests.

Aside from the bread and butter changes to payments for individual services, the proposed rule also includes the CMS’ first statements on a move toward the new Merit-Based Incentive Payment System created under the Medicare Access and CHIP Reauthorization Act, the law that put an end to the sustainable growth rate formula.

The new incentive system will replace the Physician Quality Reporting System and Medicare’s value-based modifier in 2019. In the meantime, the CMS has included all eight pathology measures for PQRS in its proposed rule. That includes two new measures on lung cancer reporting (for biopsy/cytology specimens and resection specimens, respectively) and another new measure for melanoma reporting.

While the PQRS will end in 2018, that also is the year when a two percent across-the-board penalty would be applied to eligible pathologists or group pathology practices that do not participate in the program in 2016. Those who are eligible and do participate in 2016 would not see their Medicare pay affected for good or ill. The CAP has clarified that participation in an accountable care organization satisfies PQRS requirements.

Similarly, the agency’s value-based modifier would hit all eligible physicians in 2018 based on how well they do next year on cost and quality metrics. Pathologists judged to provide low-quality, high-cost care in groups of 10 or more eligible CMS providers would see a four percent penalty, while pathologists in smaller group practices would face a two percent cut. Meanwhile, pathologists judged to provide high-quality, low-cost care could see a four percent Medicare pay increase.

“Many of these measures are, in general, constructed around the typical office-based physician practice and are harder to apply to pathologists,” W. Stephen Black-Schaffer, MD, said during the CAP webinar. He is vice chair of the College’s Economic Affairs Committee.

“One of CAP’s recent advocacy efforts has been to include a provision which directs the secretary of the HHS to consult with non-office-based physicians, typically referred to as non-patient-facing physicians, to develop alternative measures for their categories,” Dr. Black-Schaffer said. “CAP plans to engage with CMS on this. We anticipate the significance of this will become greater over time. One of the things we got when we had the SGR taken away was the expectation that in the future adjustments of this sort will be predicated primarily on this sort of performance score rating.”

Comments on the proposed physician fee schedule are due by Sept. 8.

Medicare’s move toward value-based care also is reflected in the other major proposal published in July and available at https://federalregister.gov/a/2015-16577. The CMS, in its proposed rule on hospital outpatient and ambulatory surgical center payment, presented further bundling of hospital outpatient payment for ancillary services—including certain laboratory and pathology services—into what it calls ambulatory payment classifications.

Notably, the agency excluded from its packaging policy all “molecular pathology tests described by CPT codes in the ranges of 81200 through 81383, 81400 through 81408, and 81479.” Those codes listed in the clinical laboratory fee schedule will continue to be paid at CLFS rates, outside the outpatient prospective payment system, the proposal said.

The agency also says it erred in its estimates about the value of the clinical laboratory services that would be swept into its outpatient bundling program. The CMS had expected that $2.4 billion in laboratory tests would be shifted into the packaging initiative, but only $1.4 billion actually was, with the other $1 billion paid separately. To make up for that, the agency proposed cutting the 2016 conversion factor by two percent. The deadline for comments on the proposed Hospital Outpatient Prospective Payment System rule is Aug. 31.

Kevin B. O’Reilly is CAP TODAY senior editor.