CMS Halts Plan to Cap Pathology Payments to APC Rates, Payment for Other Key Services is Reduced

Driving home on Wednesday for the Thanksgiving holiday – this headline hit the inbox late on the 27th.  As expected, some reimbursement cuts to key pathology and laboratory tests. The Pathology Blawg has a far better write up on this than I could go into with some short analysis and commentary of the bevy of changes – good, bad and indifferent, at least for the time being with many matters still “on ice” to be “re-investigated at a later date” before a final rule is enacted.

I would encourage you to check out The Pathology Blawg for a deeper dive than what is below on some of the more common codes and educate yourself on G codes if anyone has a good reference/link for these

From CAP  (11/27/2013; 6:15 PM):

Today, the Centers for Medicare and Medicaid Services (CMS) announced its final 2014 Physician Fee Schedule (PFS) and Hospital Outpatient Prospective Payment System (HOPPS) rules, in which CMS halted its plan to cap payment rates in 2014 in the Medicare physician fee schedule at Hospital Outpatient Ambulatory Classification (APC) Rates. Additionally, CMS 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 full list of final rules are available online.

2014 Anatomic Pathology Code Revaluations

For a full table outlining the proposed changes, visit the CAP’s website.

As expected, the final rule included 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. CMS established the requirement to use new G codes to bill services going forward.
• Enhanced Cytology Services: 88112 (PC & TC) – CMS accepted the RUC recommendation to reduce values for the PC & TC.
• In situ hybridization services: 88365, 88367, and 88368 (PC & TC) – CMS deferred action on revaluation of PC & TC until 2015.
• 88305 TC – CMS did not reduce valuation for the TC.
• New Restrictions on Prostate Biopsies – CMS imposed new restriction 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.