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2015 Medicare Payment Changes

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Presentation on theme: "2015 Medicare Payment Changes"— Presentation transcript:

1 2015 Medicare Payment Changes
How the Final Physician Fee Schedule Rule Impacts Pathologists PRESENTED BY Jonathan L. Myles, MD, FCAP Mark S. Synovec, MD, FCAP John H. Scott, Vice President, CAP Advocacy and Policy DATE November 5, 2014

2 Agenda Welcome Payment for Pathology Services
Our Presenters CAP Advocacy and Policy Payment for Pathology Services Quality Reporting Initiatives Local Coverage Determinations Questions © 2014 College of American Pathologists. All rights reserved.

3 Our Presenters Jonathan L. Myles, MD, FCAP
Chair, CAP Economic Affairs Committee Pathology Advisor to the AMA RUC © 2014 College of American Pathologists. All rights reserved.

4 Our Presenters Mark S. Synovec, MD, FCAP
Advisor, Council on Government and Professional Affairs Liaison, AMA House of Delegates Member AMA CPT Editorial Panel © 2014 College of American Pathologists. All rights reserved.

5 Payment for Pathology Services
Impact on services targeted by CMS as misvalued Immunohistochemistry Prostate Biopsy G-code In Situ Hybridization Services (FISH) Comparing Physician Payment to Hospital Data © 2014 College of American Pathologists. All rights reserved.

6 Payment for Pathology Services
© 2014 College of American Pathologists. All rights reserved.

7 Immunohistochemistry
CMS created IHC G-codes for 2014 CAP advocated for alternative Proposed changes to CPT codes CAP developed code change proposals Led valuation efforts aimed at addressing CMS’ concerns with overpayment in order to protect reimbursement CMS accepted the CAP’s code recommendations for IHC CMS lowered value for add-on code This slide is intended to provide the audience participants with background © 2014 College of American Pathologists. All rights reserved.

8 Immunohistochemistry
88342 (Immunohistochemistry or immunocytochemistry, per specimen; initial single antibody stain procedure) (For quantitative or semiquantitative immunohistochemistry, see 88360, 88361) (88343 has been deleted. For multiplex antibody stain procedure, use 88344)

9 Immunohistochemistry
88341 (Immunohistochemistry or immunocytochemistry, per specimen; each additional single antibody stain procedure (List separately in addition to code for primary procedure) (Use in conjunction with 88342) (For multiplex antibody stain procedure, use 88344)

10 Immunohistochemistry
88344 (Immunohistochemistry or immunocytochemistry, per specimen; each multiplex antibody stain procedure) (Do not use more than one unit of 88341, 88342, for each separately identifiable antibody per specimen) (Do not report 88341, 88342, in conjunction with 88360, unless each procedure is for a different antibody)

11 Immunohistochemistry
(When multiple separately identifiable antibodies are applied to the same specimen [ie, multiplex antibody stain procedure], use one unit of 88344) (When multiple antibodies are applied to the same slide that are not separately identifiable, [eg, antibody cocktails], use 88342, unless an additional separately identifiable antibody is also used, then use 88344)

12 Immunohistochemistry
Physician Work RVU Global Payment PC Payment TC Payment 2013 88342 .85 $115.34 $42.19 $73.15 2014 G0461 (first) .60 $88.48 $30.81 $57.67 2014 G0462 (additional) .24 $68.42 $12.54 $55.88 (initial) .70 $90.58 $36.52 $54.06 (additional) .42 $67.31 $21.84 $45.47 (multiplex) .77 $117.07 $40.10 $76.97

13 Prostate Biopsy G-code
CMS finalized its proposal for 2015 Use G0416 to report prostate biopsy services, regardless of specimens, in 2015 Applies to all prostate biopsy specimens 1-9 Other prostate G-codes and no longer valid in 2015 CAP had urged the CMS to withdraw the proposal © 2014 College of American Pathologists. All rights reserved.

14 Prostate Biopsy G-code
2015 payment is the same as 2014 CMS believes the service is misvalued Wants the service to be revalued for 2016 Now, CAP will lead RUC review of the service 2015 Global 2015 TC G0416 $649.08 $182.59 $466.49 88305 $73.03 $39.02 $34.01 G0416/88305 8.89 4.68 13.72 © 2014 College of American Pathologists. All rights reserved.

15 In Situ Hybridization Services (FISH)
CAP advocated for CPT code changes to address CMS’ payment concerns for the service FISH codes have been under review for several years National Correct Coding Initiative (NCCI) manual included reporting limits Sought to avoid CMS creating more G-codes © 2014 College of American Pathologists. All rights reserved.

16 National Correct Coding Initiative (NCCI)
NCCI Policy Manual Separate process which impacts payment for physician services Last year’s manual limited payment for FISH services December release anticipated CAP will review and comment prior to January 1 effective date

17 National Correct Coding Initiative (NCCI)
Medically Unlikely Edits, NCCI Coding Edits Code edit pairs and limitations set by CMS through NCCI CAP reviews draft edits and provides feedback to CMS If published, edits will appear on CMS website December release anticipated

18 In Situ Hybridization Services (FISH)
88365 In situ hybridization (eg, FISH), per specimen; initial single probe stain procedure In situ hybridization (eg, FISH), per specimen; each additional single probe stain procedure (List separately in addition to code for primary procedure) (Use in conjunction with 88365) © 2014 College of American Pathologists. All rights reserved.

19 In Situ Hybridization Services (FISH)
88366 In situ hybridization (eg, FISH), per specimen; each multiplex probe stain procedure (Do not report 88365, in conjunction with 88367, 88368, 88374, for the same probe) Morphometric analysis, in situ hybridization (quantitative or semi-quantitative), using computer-assisted technology, per specimen; initial single probe stain procedure © 2014 College of American Pathologists. All rights reserved.

20 In Situ Hybridization Services (FISH)
88373 Morphometric analysis, in situ hybridization (quantitative or semi-quantitative), using computer-assisted technology, per specimen; each additional single probe stain procedure (List separately in addition to code for primary procedure) (Use in conjunction with 88367) © 2014 College of American Pathologists. All rights reserved.

21 In Situ Hybridization Services (FISH)
88374 Morphometric analysis, in situ hybridization (quantitative or semi-quantitative), using computer-assisted technology, per specimen; each multiplex probe stain procedure (Do not report 88367, in conjunction with 88365, 88366, 88368, for the same probe)

22 In Situ Hybridization Services (FISH)
88368 Morphometric analysis, in situ hybridization (quantitative or semi-quantitative), manual, per specimen; initial single probe stain procedure Morphometric analysis, in situ hybridization (quantitative or semi-quantitative), manual, per specimen; each additional single probe stain procedure (List separately in addition to code for primary procedure) (Use in conjunction with 88368)

23 In Situ Hybridization Services (FISH)
88377 Morphometric analysis, in situ hybridization (quantitative or semi-quantitative), manual, per specimen; each multiplex probe stain procedure (Do not report or in conjunction with 88365, 88366, 88367, for the same probe) (For morphometric in situ hybridization evaluation of urinary tract cytologic specimens, see 88120, 88121)

24 In Situ Hybridization Services (FISH)
Qualitative Physician Work RVU Global Payment PC Payment TC Payment 2013 88365 1.20 $178.62 $58.18 $120.44 2014 $177.32 $60.18 $117.14 2015 88365 (initial) .88 $157.17 $44.75 $112.42 88364 (additional) .53 $97.38 $27.21 $70.17 88366 (multiplex) 1.24 $150.01 $63.73 $86.28 © 2014 College of American Pathologists. All rights reserved.

25 In Situ Hybridization Services (FISH)
Quantitative, Computer Assisted Physician Work RVU Global Payment PC Payment TC Payment 2013 88367 1.30 $258.23 $59.88 $198.35 2014 $255.77 $62.69 $193.08 2015 88367 (initial) .73 $107.40 $35.44 $71.96 88373 (additional) .43 $60.15 $21.12 $39.02 88374 (multiplex) .93 $205.14 $45.11 $160.03 © 2014 College of American Pathologists. All rights reserved.

26 In Situ Hybridization Services (FISH)
Quantitative, Manual Assisted Physician Work RVU Global Payment PC Payment TC Payment 2013 88368 1.40 $232.04 $61.58 $170.46 2014 $232.49 $64.84 $167.65 2015 88368 (initial) .88 $108.84 $41.17 $67.66 88369 (additional) .53 $73.75 $25.06 $48.69 88377 (multiplex) $214.45 $65.52 $148.93 © 2014 College of American Pathologists. All rights reserved.

27 CMS Rejection of Direct Practice Expense Cost Inputs
TC and Global fees include direct practice expense costs for medical supplies, equipment and clinical labor CMS cut or reduced key practice expense cost Supply items rejected for FISH codes Incorrect lower cost supplies substituted for IHC Clinical staff time reduced for microdissection CAP is advocating to restore cost items reduced or deleted by CMS to improve payment rates © 2014 College of American Pathologists. All rights reserved.

28 Comparing Physician Payment to Hospital Data
Code families for 22 services reviewed to prevent use of hospital data for setting technical and global payments For 2015, CMS did not take action on practice expense recommendations from the RUC associated with 22 pathology code families. CMS Response: Continue to review use of other sources such as hospital cost data to review code values © 2014 College of American Pathologists. All rights reserved.

29 Payment for Pathology Services
Optical Endomicroscopy – Interpretation 88375 CMS reversed its 2014 decision not to pay separately on the fee schedule and implemented Medicare payment based on CAP request. © 2014 College of American Pathologists. All rights reserved.

30 Payment for Pathology Services
88375 Optical endomicroscopic image(s), interpretation and report, real-time or referred, each endoscopic session (Do not report in conjunction with or 43252) 88375 Year Physician Work RVU Global Payment 2014 I - Inactive for Medicare 2015 .91 $46.54 © 2014 College of American Pathologists. All rights reserved.

31 Payment for Pathology Services
Microdissection 88380 and 88381 CMS accepted RUC-approved values developed by CAP © 2014 College of American Pathologists. All rights reserved.

32 Payment for Pathology Services
88380 Microdissection (ie, sample preparation of microscopically identified target); laser capture 88380 Year Physician Work RVU Global Payment PC Payment TC Payment 2014 1.56 $190.58 $80.24 $110.33 2015 1.14 $132.82 $76.26 $56.57 © 2014 College of American Pathologists. All rights reserved.

33 Payment for Pathology Services
88381 Microdissection (ie, sample preparation of microscopically identified target); manual (Do not report in conjunction with 88381) 88381 Year Physician Work RVU Global Payment PC Payment TC Payment 2014 1.18 $160.84 $55.17 $105.68 2015 .53 $124.59 $26.13 $98.45 © 2014 College of American Pathologists. All rights reserved.

34 Payment for Pathology Services
Cytopathology CMS identified as potentially misvalued CMS reviewed values for cytopathology service – and questions 88108 Flow cytometry CMS identified TC add-on code as potentially overvalued Requested review for 2016 payment change © 2014 College of American Pathologists. All rights reserved.

35 Quality Reporting Initiatives
Physician Quality Reporting System Physician Value-Based Modifier (VBM) © 2014 College of American Pathologists. All rights reserved.

36 Physician Quality Reporting System
The College is pleased that the CMS included three new pathology measures in the 2015 PQRS. The measures are: Lung cancer reporting (biopsy/cytology specimens) Lung cancer reporting (resection specimens) Melanoma reporting Register for the CAP’s December 2 PQRS Webinar © 2014 College of American Pathologists. All rights reserved.

37 Physician Value-Based Modifier (VBM)
VBM will apply to all physicians in 2017 2015 PQRS will affect 2017 PQRS, VBM penalties - 4% VBM penalty for physicians in groups 10 or more - 2% VBM penalty for solo physicians, groups 2-9 Separate -2% penalty under PQRS program Successful PQRS participation in 2015 can stop the 2017 penalties © 2014 College of American Pathologists. All rights reserved.

38 LCD Process Changes CMS proposed several Medicare Local Coverage Determination process changes Expand Palmetto’s MolDX program Shorten public comment period to 30 days from 45 days Limited opportunities to suggest improvements to draft LCDs CAP vigorously opposed the CMS’ proposal CMS stated it would not move forward, but it would explore rulemaking on this issue in the future © 2014 College of American Pathologists. All rights reserved.

39 Resources CAP.org 2015 Policy Meeting STATLINE
May 4-6, 2015, Washington, DC STATLINE © 2014 College of American Pathologists. All rights reserved.

40

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