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ePolicy News Special Edition Nov. 2012

Monday, November 5, 2012

CMS Publishes PFS Shocker: Agency Guts 88305 Reimbursements by 52 Percent;

Places New Molecular Pathology Codes on CLFS

Reimbursement for the Technical Component of 88305 will be reduced 52 percent and the 101 new molecular pathology codes will be assigned to the clinical laboratory fee schedule, the Centers for Medicare and Medicaid Services (CMS) announced when it published its CY 2013 Physician Fee Schedule (PFS) Final Rule today. The rule also outlines that PFS reimbursement rates will be cut 27 percent due to the impact of the flawed sustainable growth rate. It is widely expected, however, that Congress will take action to prevent the SGR-related cuts from going into effect.

The Final Rule indicates that CMS will cut the technical component of CPT 88305 (Level IV, surgical pathology, gross and microscopic examination) by 52 percent. However, the agency indicated it would increase the professional component rate for 88305 by 2 percent.

In addition, CMS plans to place the 101 new molecular pathology codes on the Clinical Laboratory Fee Schedule (CLFS), despite unified support from ASCP and the rest of the pathology community for placing the codes on the PFS. In announcing its decision, CMS stated, “after reviewing the public comments, we believe that the molecular pathology CPT codes describe clinical laboratory diagnostic laboratory tests that should be paid under the CLFS because these services do not ordinarily require interpretation by a physician to produce a meaningful result.” That said, CMS also wrote that it believes that, “in some cases, a physician interpretation of a molecular pathology test may be medically necessary to provide a clinically meaningful, beneficiary-specific result.”

To enable physician reimbursement for this, CMS has “created a HCPCS G-code, G0452 (molecular pathology procedure; physician interpretation and report) to describe medically necessary interpretation and written report of a molecular pathology test. CMS indicated that “[t]his professional component-only HCPCS G-code will be considered a ‘clinical laboratory interpretation service,’ which is one of the current categories of PFS pathology services under the definition of physician pathology services.” CMS indicated that the G-code will be temporary and that the agency will be monitoring the code to assess whether billing requests are appropriate for the technical service that was interpreted.

CMS also outlined details for the CY 2013 Physician Quality Reporting System (PQRS) program. The program requires pathologists to report data on applicable PQRS quality measures. Providers who satisfy reporting requirements can receive a 0.5 percent bonus in CY 2013 on overall allowed Medicare Part B charges. Those pathologists who successfully meet the reporting requirements will also escape the 1.5 percent penalty for failure to meet reporting requirements in 2015 (and -2 percent thereafter). CMS also indicated that it was approving several new ASCP-supported pathology quality measures, bringing the total to five measures pathologists may use. These measures are as follows: Breast Cancer Resection Pathology Reporting, Colorectal Cancer Resection Pathology Reporting, Barrett’s Esophagus, Radical Prostatectomy Pathology Reporting, and Immunohistochemical (IHC) Evaluation of Human Epidermal Growth Factor 2 Testing (HER2) for Breast Cancer Patients. To satisfy reporting requirements, physicians must report data on three quality measures.

Importantly for pathologists, CMS altered the group reporting option to facilitate reporting as a smaller group practice, rather than individually. Group practices with 2 to 99 members can report as a group, enabling all group members to receive an incentive payment (and avoid penalties) irrespective of who in the group provided the data necessary to meet the group reporting requirements.

The rule also formalizes the end of the TC Grandfathering provisions.