Half a loaf from the CMS?

Jan. 13, 2014
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 Rates. CMS has also 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).

The final rule includes payment reductions to the following pathology code families: immunohistochemistry; enhanced cytology services, and in situ hybridization services; and adds new restrictions on prostate biopsies.

Though CMS has halted the plan to cap payment rates, it says it will revise and reissue a proposal in the future. The College of American Pathologists (CAP), the American Society for Clinical Pathology (ASCP), and others in the laboratory community are expressing concern that CMS has, in effect, only postponed such a proposal.

As the CAP has pointed out, “under the Affordable Care Act, CMS has the authority to launch its ‘misvalued code’ initiative. CMS targeted the top expenditure codes from each specialty as potentially overvalued.” These code restrictions went into effect on
January 1.

CAP provides relevant background: Last July, “the agency proposed linking payment for more than 200 services to hospital outpatient rates” as part of the initiative. “The rule released would have reduced the technical component and global payment of 39 pathology services billed for non-hospital patients by as little as 4% and as much as 80% depending on the services.” CAP notes that the CMS has also rejected the idea that the  RUC process is reliable to establish expenses.

CAP President Gene N. Herbek, MD, FACP, says, “The CAP, through its seat at the table with the RUC, strongly advocated on behalf of its members…the CAP will continue to work with CMS to ensure that the revaluations of pathology services accurately account for the cost of delivering services.”

ASCP voiced similar concerns, particularly with regard to CMS’ plans to review—and, potentially, revalue—all 1,250 codes on the Clinical Laboratory Fee Schedule.  ASCP also has sounded the alarm about the agency’s plans to bundle reimbursements.

“We are thankful that CMS eliminated the proposed rate cap, but are concerned that the other decisions could disrupt the affordable supply of life-saving diagnostic services for patients,” says ASCP President Steven Kroft, MD, FASCP. “This could result in reduced access to needed laboratory services, inadequate compensation for services, and increased administrative burden.”

Do you like to curl up with a long book? You can access the CMS’ “Medicare Program; Revisions to Payment Policies under the Physician Fee Schedule, Clinical Laboratory Fee Schedule and Other Revisions to Part B for CY 2014”—all 1,369 pages of it—at the Office of the Federal Register website. (http://www.ofr.gov/inspection.aspx)Scroll down until you see the title.

The CMS may have given pathologists rather less than half a loaf; it may be more like a few slices. I’d be interested to know what readers think about the agency’s decisions, and the prospects for future action.