Advocacy Update

• CAP Asks CMS to Clarify Pathology Clinical Consultation Codes Before Implementation
• CAP Urges CMS to Create Equitable, Balanced System with No Surprises Act Regulations
• CAP Provides Critical Feedback on Patent-Reform
• This Is the Week of Action to Fight Medicare Cuts
• Check out the Advocacy Town Hall at CAP 21
• New Month, New Advocacy News Quiz

The CAP successfully advocated to include new CPT codes for pathology clinical consultation services in the proposed 2022 Medicare Physician Fee Schedule but urged the Centers for Medicare & Medicaid Services (CMS) to clarify the codes before implementation. Additionally, the CAP asked the CMS to relieve some quality reporting burdens for pathologists as the CAP advocates to ensure adequate reimbursement coverage issues facing pathologists.

Pathology Consult Codes Implementation

In a September 13 letter to the CMS, the CAP outlined how the CMS should view and implement the pathology clinical consultation codes next year. The CAP worked with the American Medical Association’s (AMA) CPT Editorial Panel to craft new pathology clinical consultation codes and develop payment rates through its role in the AMA/Specialty Society Relative Value Scale Update Committee (RUC). As a result, the CMS accepted the new code family proposed by the CAP in the 2022 Medicare proposed fee schedule.

The CMS adopted the CAP developed relative value units (RVUs) with some areas of disagreement. In the letter, the CAP encouraged the CMS to fully adopt the CAP’s recommended RVUs and disagreed “with the CMS’ assessment that the increase or decrease in time is commensurate with the increase or decrease in work RVU. The code set 80XX0 – 80XX3 represents unique and distinct services from those identified by 80500 and 80502. 80500 and 80502 are almost 25 years old and represented different services and should not be used for comparison,” the CAP stated.

The AMA RUC adopted the CAP’s developed values from pathologist’s survey data for these services. The surveys measured their clinical judgment, mental effort, technical skill, and psychological stress relative to other physician fee schedule CPT codes, to develop the amount of physician work and time for each code. The CAP urged the CMS to embrace the RUC processes in its final 2022 fee schedule valuations.

Proposed 2021 Merit-based Incentive Payment Program (MIPs)

Also, in the September 13 letter, the CAP advocated to increase flexibility for pathologists in a way that recognizes and accounts for the value pathologists play in patient care as non patient-facing clinicians in an inherently patient-facing program. These considerations will be especially important as the CMS moves forward with implementing the Merit-based Incentive Program (MIPS) Value Pathways (MVPs) in the Quality Payment Program (QPP). Additionally, the CAP responded to the digital quality measures and health equity requests for information (RFI). It urged the CMS to consider the CAP’s concerns before implementing policies included in these RFIs.

The CAP called for strong regulations to prevent health plan manipulation in a September 7 letter to the CMS regarding a recent surprise billing interim final rule. The CAP further called on the CMS to ensure “that regulations must support an equitable and balanced system for resolving payment disputes, so as to ensure fair reimbursement for out-of-network services and an independent dispute resolution (IDR) process that is accessible to all.”

On July 1, the Department of Health and Human Services (HHS) and other agencies issued regulations implementing portions of the No Surprises Act that bars surprise billing. Prior to the regulation’s release, the CAP provided key recommendations to the HHS. The No Surprises Act, which became law in December 2020 and goes into effect on January 1, 2022, included several provisions advocated for by the CAP.

The interim final rule only addressed parts of the No Surprises Act, including areas where Congress set a specific statutory rulemaking deadline of July 1, 2021. The CAP expects that the rules detailing the IDR process will be released later this year.

In its official comment letter, the CAP asked the CMS to differentiate and clarify how the federal law would work with current state laws protecting patients from surprise medical bills. “The CAP generally supports allowing state laws to continue to operate and improve their patient protections,” the CAP stated in the letter. “However, we still feel that additional clarity would be helpful around where and explicitly how state law applies. We encourage the agency to provide ongoing education and resources in this area, beyond the initial examples.” The CAP also argued that relying on an initial/benchmark rate for out-of-network services, especially those based on median or mean in-network contract rates, is contrary to the legislative intent of the No Surprises Act and would create imbalance and threaten patient access in the U.S. health care system

The CAP will continue to work with the CMS and other agencies as they develop the final regulations for the No Surprises Act.

The CAP has outlined how gene patenting needs to have patent-eligibility, and that no single company or group should have sole jurisdiction on gene patenting. In a September 3 letter to the US Patent and Trade Office (USPTO), the CAP explained its position in three areas asked by the USPTO on gene patenting: Observations and Experiences in Gene Patenting, Precision Medicine, and Diagnostic Methods. Citing patient safety concerns, the CAP has long opposed gene patenting.

As genomic medicine evolves, it will become a cornerstone of medical diagnostics, requiring specialized medical knowledge in test selection, interpretation, and integration of test results with patients' medical history. The CAP sent a letter to the USPTO detailing how the patenting of genes and other laws of nature, natural phenomena, products of nature, and abstract ideas would negatively impact the practice of medicine and patient care.

“Patents over genes and gene sequences pose a serious threat to patient care, medical advancement, and medical education,” the CAP stated in the letter. “Allowing commercial entities to patent genes will impede the provision of genetic-based clinical testing and patient care through exclusive license agreements, excessive licensing fees, and restrictive licensing conditions.”

The CAP further discussed how a single entity should not have diagnostic ownership of specific diseases or serve as gatekeepers for therapeutic treatments. “If gene sequences and other natural phenomena can be considered intellectual property, a company with monopoly rights over the related disease can significantly hinder critical research,” the CAP emphasized.

The CAP also reinforced that "patent reform must maintain the judicially created exceptions to patent-eligibility as restricted by the Mayo, Myriad, and Alice decisions.” In addition, patent reform should not ignore the patenting of human genes and naturally occurring associations between genes and disease, as it would create barriers to patients’ access to lifesaving genetic/genomic tests.

The CAP understands how pathologists have a vested interest in ensuring that patent reform does not restrict the ability of physicians to provide quality diagnostic services to patients.

  This week, the CAP is asking its members to join in a Grassroots Week of Action to urge their federal legislators to extend the 3.75% relief provided in the Consolidated Appropriations Act of 2021 for the next two years.

At the end of 2020, the CAP successfully lobbied Congress to pass legislation mitigating the impact of the Medicare cuts from 9% to about 2% to 3% in 2021, saving pathologists nearly $85 million in lost revenue. The CAP is again asking Congress to extend the 3.75% relief it provided in the Consolidated Appropriations Act of 2021 for 2022 and 2023. The CAP urges its members to check out the CAP’s Twitter page at @CAPDCadvocacy every day at 12 PM ET to learn more and check emails from the CAP for how to act as a united voice.  

With extraordinary pressures on pathologists due to the COVID-19 pandemic, the CAP is seeking an extension of the relief Congress passed last year. As such, the CAP and its members are urging Congress to appropriate an additional $3 billion to extend the current relief and provide sufficient time to develop a longer-term solution.

Learn more here.

Are you attending the upcoming CAP21 annual meeting? Then join CAP President-elect Emily Volk, MD, FCAP, and Chair of the CAP Council on Government and Professional Affairs Jonathan Myles at the CAP Advocacy Town Hall on Monday, September 27 at 8 AM CT. Watch as CAP House of Delegates Speaker Kathryn Knight, MD, FCAP, moderates an engaging forum on current health care policy matters, including private payer rates in your state, or the impact of federal legislation in Washington, DC. Tune in and gain the insights important to you and your practice.

Register today

It’s September which means a new Advocacy News Quiz featuring the CAP’s 75th Anniversary. Last month almost 100 members took the quiz! Test your knowledge and win a 75th Anniversary prize for completing the quiz.

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