Special Advocacy Update

• CAP-Developed Pathology Consult Codes Finalized for Medicare Payment in 2022
• CMS Updates Medicare Quality Payment Program Requirements for Next Year

Pathologists will have new CPT codes for pathology clinical consultation services in 2022 after the Medicare program included codes developed by the CAP in its final 2022 Medicare Physician Fee Schedule. The Centers for Medicare & Medicaid Services (CMS) published the fee schedule on November 2. The CAP has advocated for including new and improved codes and values for pathology clinical consultation services on the Medicare fee schedule.

The CAP worked with the American Medical Association’s (AMA) CPT Editorial Panel to establish pathology clinical consultation codes and develop new payment rates through the CAP’s role in the AMA/Specialty Society Relative Value Scale Update Committee (RUC). The CAP leads all reviews of pathology services that go before the RUC.

The four new pathology clinical consultation services describe physician pathology clinical consultation services provided at the request of another physician or qualified health care professional at the same or another facility or institution. The distinction among the new code family involves a degree of complexity and/or time of service, broken down by 20-minute increments each for codes 80503, 80504, and 80505, along with an add-on code 80506 reflecting additional 15–30-minutes above that spent on CPT 80505.

According to CPT, the pathology clinical consultation services (80503, 80504, 80505, 80506) may be reported when the following criteria have been met:

• The pathologist renders a pathology clinical consultation at the request of a physician or qualified healthcare professional at the same or another institution.
• The pathology clinical consultation request is in relation to pathology and laboratory findings or other relevant clinical or diagnostic information requiring additional medical interpretative judgment.

A pathologist may also render a pathology clinical consultation when mandated by federal or state regulation (eg. Clinical Laboratory Improvement Amendments).

Final Medicare Fee Schedule Impact on Pathology Payment

Overall, pathologists are facing a Medicare cut of about 3.71% next year. This reduction is due to the final 2022 conversion factor of $33.5983, representing a 3.71% decrease from 2021. This 3.71% decrease to the conversion factor stems from Medicare policy to offset increases to other physician services such as any increases to evaluation and management services.

The CAP has lobbied Congress throughout 2021 to appropriate an additional $3 billion to reduce reimbursement decreases to pathologists and other physicians affected by the cuts.

Review all the payment changes to pathology services in our final 2022 Medicare Physician Fee Schedule Impact Table.

CAP Advocacy Averts 1% Reduction in Reimbursements

In the proposed rule for 2022, pathologists were set to face an additional Medicare cut of 1% due to an update to practice expense clinical labor rates. However, thanks to CAP advocacy, the CMS agreed to delay that update, averting the additional 1% cut to pathology services.

What Will Be the Impact of the Final Fee Schedule on Your Practice?

CAP members can learn more about the final fee schedule changes by attending a complimentary webinar on December 3 at 1 PM ET where experts will review the finalized 2022 Medicare regulations and their impact on payment for pathology services.

Register today

Also on November 2, the CMS published its final regulation for the 2022 Quality Payment Program (QPP). According to the final regulation, nearly all pathologists will be required to participate in Medicare’s QPP either through Advanced Alternative Payment Models (APMs) or the Merit-based Incentive Payment System (MIPS).

The CAP has long advocated reducing MIPS reporting burdens for pathologists.

In this regulation, the CMS finalized program changes that move the program forward and introduced additional complexities. This includes moving away from traditional MIPS to MIPS Value Pathways (MVPs); CMS will begin gradual implementation of MVPs starting with the 2023 performance year.

Final 2022 MIPS Reporting for Pathologists

In 2022, pathologists eligible for Medicare’s MIPS program will have to take action to avoid penalties that reduce future Medicare Part B payments for their services. Performance in MIPS in 2022 affects Medicare Part B payments in 2024 by +/-9%. However, the CMS acknowledged the upside potential has not provided to clinicians the expected return on their investment in MIPS.

In its final 2022 QPP regulations, the CMS increased the Performance Threshold to avoid a penalty to 75 points from the current 60 points. The CMS also increased the exceptional Performance Threshold to 89 points from the current 85 points. Additionally, 2022 is the last year of the exceptional performance threshold and the associated additional bonus pool positive payment adjustment.

The CMS finalized some scoring changes for quality measures but delayed others due to the COVID-19 pandemic. Overall, these scoring changes help pathologists, with the exception of the removal of bonus points.

• Maintaining the 3-point floor for measures that can be scored against a benchmark. CMS delayed to 2023 that measures without a benchmark or that don’t meet case minimum requirements would earn 0 points, with an exception for small practices.
• Removing bonus points for reporting additional outcome and high priority measures, beyond the one required.
• Establishing a 7-point floor for the first performance period and a 5-point floor for the second performance period for new measures, which is in line with the CAP’s advocacy.
• The CMS also finalized changes to its reweighting policies for small practices, which the CAP had previously advocated. Starting in 2022, these practices will be reweighted so that quality and Improvement Activities are each worth 50% of their MIPS score. Previously, pathologists in small practices who were not scored in the Promoting Interoperability and Cost categories of MIPS had their MIPS score reweighted, so that quality was 85% of their score and Improvement Activities were 15%.

The Pathology Specialty Measure Set will remain the same as 2021 containing six quality measures, including an American Academy of Dermatology (AAD) stewarded measure QPP 440 (Skin Cancer: Biopsy Reporting Time – Pathologist to Clinician). While the CAP recognizes the importance of prompt turnaround of biopsy reports, we are working with the CMS and the AAD to mitigate the operational challenges pathologists encounter when using this measure.

As a direct result of advocacy from the CAP, the CMS finalized a CAP-proposed improvement activity on implementing a laboratory preparedness plan to support continued or expanded patient care during COVID-19 or another public health emergency. The CAP has actively worked with the CMS to demonstrate the need for more appropriate and alternate measures and improvement activities so that pathologists can more fully participate in MIPS.

The CAP encourages pathologists to assess their MIPS reporting options. The CAP has invested in a registry that is the only MIPS reporting option with measures that potentially allow pathology practices reach the scoring threshold to avoid a penalty, plus the potential to reach the exceptional performance threshold.

Advanced Alternative Payment Models

For those pathologists who practice in an Alternative Payment Model (APM), the final 2022 QPP makes minimal changes to the Advanced APM track while adding transition time for accountable care organizations in the Medicare Shared Savings Program (MSSP). The transition time enables accountable care organizations to report on certain quality measures and increase flexibility related to the MSSP quality performance standard. The CMS also finalized a hierarchy and other minor adjustments to help better identify potential payee Taxpayer Identification Numbers (TINs) as a means of improving the agency’s ability to complete payments to more qualifying physicians.

What Do The 2022 Final QPP Regulations Mean For Your Practice

The CAP will review the provisions included in the finalized regulation during a member-exclusive webinar on December 3 at 1 PM ET.

Register today