CMS halts plan to cap pathology payments to APC rates, reduces payment for other services

Dec. 9, 2013

The Centers for Medicare and Medicaid Services (CMS) has announced its final 2014 Physician Fee Schedule (PFS) and Hospital Outpatient Prospective Payment System (HOPPS) rules. The CMS has halted its plan to cap payment rates in 2014 in the Medicare physician fee schedule at Hospital Outpatient Ambulatory Classification (APC) Rates. Additionally, CMS has reduced payment for certain Anatomic Pathology codes and expanded bundling of payments for all clinical laboratory tests (other than molecular pathology tests) performed on hospital outpatients that are currently billed to the Clinical Laboratory Fee Schedule (CLFS).

As expected, the final rule includes payment reductions to the following pathology code families:

  • Immunohistochemistry: 88342 (PC & TC) – CMS rejected the code change proposal but accepted the American Medical Association (AMA)/Specialty Society Relative Value Scale Update Committee (RUC) recommendation to reduce the value of both the PC & TC.
  • Enhanced Cytology Services: 88112 (PC & TC) – CMS accepted the RUC recommendation to reduce value for the PC & TC.
  • In situ hybridization services: 88365, 88367, and 88368 (PC & TC) – CMS deferred action on revaluation of the PC & TC until 2015.
  • 88305 TC – CMS did not reduce valuation for the TC.
  • New Restrictions on Prostate Biopsies – CMS imposed new restrictions on billing of 10 or more prostate biopsies specimens and will require individuals who bill more than 10 to utilize a G code to bill.

Though CMS has halted the plan to cap payment rates, it says it will revise and reissue a proposal in the future. Spokespersons for the College of American Pathologists (CAP) and others in the laboratory community are expressing concern that CMS has, in effect, only postponed such a proposal. Read a 2014_Physician Fee Schedule Final Rule Impact Table compiled by CAP.