Special Advocacy Update

• CAP Opposes 2% Cut to Pathologists in Proposed 2024 Medicare Physician Fee Schedule
• CMS Continues to Increase Medicare Quality Payment Program Requirements for 2024
• CLIA Request for Information on Remote Sign-Out and More

The proposed 2024 Medicare Physician Fee Schedule released on July 13 outlined deep cuts to pathologists, independent laboratories, and other specialties to offset increases to other physicians. The CAP has strongly opposed these cuts and is actively lobbying Congress to mitigate the decreases before they take effect.

The Centers for Medicare and Medicaid Services (CMS) published the 2024 proposed Physician Fee Schedule and Quality Payment Program regulation and invited stakeholders to make comments in 60 days. The CAP advocates to protect the value of pathology services and will engage with the CMS to advocate for the profession. Briefly, here are the key topics included in the 2024 proposed rule:

• The CMS proposed to implement evaluation and management add-on code, G2211, causing large budget neutrality adjustments that negatively affect pathologists and other specialties throughout the physician fee schedule. Download the impact table showing the proposed changes to pathology services in 2024.
• The CMS increases Medicare Quality Payment Program (QPP) requirements for 2024.
• Learn more: Register for the CAP’s July 26 webinar providing a comprehensive overview of the proposed fee schedule changes to pathology services and the QPP.

Large Budget Neutrality Adjustments Caused by New Add-On Code

The CMS proposed to implement a new evaluation and management (E/M) add-on code, G2211, for ongoing, longitudinal patient care. This is an add-on code that physicians may list separately in addition to office/outpatient visits for new or established patients (ie, codes 99202-99215). This code may be added even when the E/M visit is done via telehealth because the CMS has permanently added the code to the Medicare telehealth list.

The CMS is not restricting the code’s use to certain specialties but assumes some physicians will utilize the services more than others. In fact, once fully adopted the CMS assumes physicians who rely mainly on office/outpatient E/M visits will report G2211 with 54% of those visits. Primary care specialties will have a higher utilization of the add-on code than other specialties. This increased spending for primary care results in across-the-board cuts to all physician payments. Specialties that do not utilize the new code see larger cuts as a result of its implementation.

The CMS said code G2211 reflects the time, intensity, and practice expense required to build longitudinal relationships with patients and address most of their health care needs with consistency and continuity over long periods of time. In the context of primary care, the CMS believes the code recognizes the resources inherent in holistic, patient-centered care that combines the treatment of illness or injury, the management of acute and chronic health conditions, and the coordination of specialty care in a collaborative relationship with a clinical care team.

The CAP successfully lobbied Congress to delay payment for G2211 in CY 2021 when CMS initially attempted to established payment for the code. The CAP will continue its advocacy efforts to protect the value of pathology services.

Proposed Regulation Impact on Pathology Payment

The 2023 proposed fee schedule indicated the overall impact to pathology payments from 2023 to 2024 would decrease by 2percent. Specifically, the proposed 2024 conversion factor used for the fee schedule’s payment formula is $32.7476, representing a 3.36% decrease from the 2023 conversation factor. This 3.36% decrease to the conversion factor also accounts for the required update to the conversion factor for 2024 of 0%, and the required budget neutrality adjustment to account for changes in relative value units and the implementation of new services. This conversion factor also takes into account a 1.25% increase for 2024 mandated by Congress last year. The CAP continues to aggressively lobby Congress to mitigate these cuts to pathologists for 2024.

AMA and Mathematica Launch New Survey Effort for 2023/2024

The CMS acknowledged the AMA-led Physician Practice Information Survey for 2023-2024 with the primary purpose to collect representative data on practice expense and hours spent in direct patient care. These data will be collected at the specialty level and shared with the CMS to update the Medicare Economic Index and the Resource Based Relative Value Scale. The AMA has contracted the firm Mathematica, an independent research company with extensive experience in survey methods as well as care delivery and finance reform, to conduct this survey. Read more about this initiative.

On July 13, the CMS published its proposed 2024 Quality Payment Program (QPP), which aims to limit changes in traditional Merit-based Incentive Payment System (MIPS) to provide clinicians continuity and consistency while they gain familiarity with their new MIPS Value Pathways (MVPs) and move toward accountable care and advanced alternative payment models. Though limited, the proposed changes to the MIPS program could have a significant impact on pathologists’ scores and payment bonuses.

The CAP has long advocated to make MIPS less burdensome for pathologists and has created measures to increase pathologists’ opportunities to demonstrate the quality they provide and score well in the program.

Proposed 2024 MIPS Reporting for Pathologists

In 2024, pathologists reporting MIPS will have to take action to avoid penalties that reduce future Medicare Part B payments for their services. Failing to reach the scoring threshold in 2024 could result in Medicare payment penalties up to 9% for payments in 2026.

In its proposed 2024 QPP regulations the CMS will:

• Raise the Performance Threshold to 82 points in order to avoid a penalty, which the CAP opposes.
• Raise the data completeness threshold (percentage of cases that need to be reported) to 75% for CY 2024, CY 2025, and CY 2026, then raise the threshold to 80% in CY 2027.
• No measures were removed from the Pathology Specialty Measure Set
• The CMS is continuing its efforts to implement MVPs, although there are no pathology-related MVPs at this time.

The CMS requests information on how to ensure physicians continually improve performance, potentially by increasing reporting requirements and/or requiring reporting on specific measures.

The CAP continues to advocate for pathologists’ success in the MIPS program. With the proposed 2024 increase is performance threshold, it is likely that many small practices –especially those that rely heavily on the topped out QPP measures-- could see a reduction in their MIPS performance scores, and this could lead to penalties. Billing companies alone are not able to avoid this problem for practices. We encourage practices (and their billing companies) to review the scoring changes and contact CAP at mips@cap.org to understand the availability of higher-scoring measures and how to best report them.

Advanced Alternative Payment Models (APMs)

The QPP includes two participation tracks for clinicians providing services under the Medicare program: MIPS and Advanced APMs. If an eligible clinician participates in an Advanced APM and achieves Qualifying APM Participant (QP) or Partial QP status, they are excluded from the MIPS reporting requirements. In this proposed rule, the CMS emphasizes that they remain steadfast in their “commitment to support providers in the transition from traditional MIPS to APMs and Advanced APMs.”

Specifically, the CMS proposes to modify the current CEHRT use criterion for Advanced APMs in order to promote flexibility and emphasize the importance of interoperability and health information technology (HIT). The CAP has previously commented on the unique challenges that pathologists face in meeting many of the typical electronic health record and HIT requirements. The CMS is also proposing to calculate QP determinations at the individual level for each unique national provider identifier (NPI) associated with an eligible clinician participating in an Advanced APM.

In an earlier request for information, the CAP expressed concern about this change, stating that a “transition to solely individual QP determinations will no doubt drive some clinicians out of APMs and increase the complexity of the program for physicians.” Finally, the proposed rule incorporates changes made by the Consolidated Appropriations Act of 2023 and supported by the CAP, including extending the APM Incentive Payment at 3.5% through payment year 2025.

The proposed regulation also included a request for information on histopathology, cytology, and clinical cytogenetics regulations under CLIA.

The request for information is soliciting feedback from the public on how to develop final regulations to achieve the following objectives:

• Developing regulations around slide staining and tissue processing as a part of the wider CLIA regulations and certification
• Making the public health emergency enforcement discretion permanent to allow pathologists to review slides remotely
• Making the public health emergency enforcement discretion permanent that allows for cytogeneticists to review images remotely

The CAP has been engaged with Clinical Laboratory Improvement Advisory Committee (CLIAC) and the CMS on ensuring CLIA regulations are appropriate since CLIA was first promulgated. The CAP will review the request for information and further provide input to the CMS.

The CAP will analyze in detail the provisions of the proposed regulation and submit comments during the agency’s 60-day comment period, which is through September 11.