Independent labs eye boon as CMS proposes to increase TC rates for key pathology services

July 16, 2018

After a slight delay, CMS released its Proposed 2019 Medicare Physician Fee Schedule late Thursday and unveiled a host of payment bumps for the technical components of several key pathology codes.

The agency proposed a roughly 8.5 percent hike for 88305-TC, which would see the payment jump to $32.81, while the code’s global rate is proposed to see a 2.7 percent increase to $72.09. However, a 1.7 percent reduction was proposed for the professional interpretation — dropping the payment to $39.29 — a move that largely foreshadowed CMS’s decision to slightly cut professional rates while boosting technical and global components for most major pathology codes.

The most significant cuts will again impact prostate biopsies, with the technical rate for G0416 being hit the hardest by a proposed 18.9 percent cut to $200.80. Meanwhile, the global rate would also see a 12 percent cut down to $384.29, while a proposed 1.8 percent reduction for the professional rate would lower the payment to $183.49.

Flow cytometry services will also experience heavy reductions, the most significant of which includes an 18.6 percent drop for 88185 (additional markers) to just $24.89. Reads for the first marker or 16-plus are also proposed to experience cuts of 2.5 and 1.9 percent, respectively.

The final conversion factor for 2019 is $36.05, a slight bump over the 2018 rate of $35.99. The overall update to payments under the MPFS based on the proposed 2019 rates is .13 percent. The update reflects the .25 percent annual increase established under the Medicare Access and CHIP Reauthorization Act (MACRA) of 2015, reduced by -.12 percent for a RVU budget neutrality adjustment, according to CMS.

The total scope of the proposed changes will see pathologists’ Medicare rates cut by 1 percent, while independent labs technical rates will jump by 4 percent overall. Finalized rates are expected to be announced in the fall, which rate changes taking effect Jan. 1, 2019.

Other notable pathology updates

As CMS continues to defend rate reductions in the Clinical Laboratory Fee Schedule triggered by the required reporting of private payer rates under the Protecting Access to Medicare Act, the agency has signaled it may be rethinking its methodology as it is now soliciting comments on whether it should expand the scope of laboratories required to report. While the narrow definition of an “applicable laboratory” resulted in pricing data being primarily gathered from national labs, CMS is now asking pathologists and industry stakeholders whether hospital outreach and physician office labs should also be included.

During the inaugural reporting period in 2017, CMS only required data from labs who received more than 50 percent of their Medicare revenue from the CLFS under their own NPI, an exclusion that left hospital labs billing under their hospital’s NPI on the outside. Now, CMS is considering allowing labs to use a CMS-1450 bill type 14x or CLIA certificate numbers to determine whether or not they are an applicable lab.

However, CMS also indicated that it feels its current collection process is adequate and that expanding the definition of an applicable lab to include more hospital labs is strictly a proposal at this point. The agency also expressed concern that these reporting requirements could place a large administrative burden on smaller labs who have difficulty collecting this data.

The next data collection period for private payer data will run from Jan. 1, 2019 to June 30, 2019. Labs will then be required to report that data between Jan. 1 and March 31, 2020. The next CLFS update will take effect on Jan. 1, 2021.

CPT Code Service Current 2018 Proposed 2019 Change
88112 – Global Cytopath cell ehance tech $70.18 $68.13 -3%
88112 – TC Cytopath cell ehance tech $40.67 $39.30 -3.4%
88112 – 26 Cytopath cell ehance tech $29.51 $28.84 -2.3%
88121 – Global Cytp urine 3-5 probes cmptr $541.65 $488.48 -9.8%
88121 – TC Cytp urine 3-5 probes cmptr $489.64 $437.65 -10.6%
88121 – 26 Cytp urine 3-5 probes cmptr $52.19 $50.83 -2.6%
88184 – TC Flowcytometry/ 1st marker $68.04 $66.33 -2.5%
88185 – TC Flowcytometry/ additional marker $30.59 $24.89 -18.6%
88189 – 26 Flowcytometry/ read 16+ $88.92 $87.24 -1.9%
88305- Global Tissue exam by pathologist $70.18 $72.09 2.7%
88305 – TC Tissue exam by pathologist $30.23 $32.81 8.5%
88305 – 26 Tissue exam by pathologist $39.95 $39.29 -1.7%
88307 – Global Level V, tissue exam by pathologist $269.93 $293.10 8.6%
88307 – TC Level V, tissue exam by pathologist $182.16 $207.27 13.8%
88307 – 26 Level V, tissue exam by pathologist $87.84 $85.80 -2.3%
88309 – Global Tissue exam by pathologist $410.04 445.28 8.6%
88309 – TC Tissue exam by pathologist $254.16 $293.45 15.5%
88309 – 26 Tissue exam by pathologist $155.88 $151.77 -2.6%
88312 – Global Special stains group 1 $99.33 $102.02 2.7%
88312 – TC Special stains group 1 $71.26 $74.26 4.2%
88312 – 26 Special stains group 1 $28.07 $27.76 -1.1%
88313 – Global Special stains group 2 $71.98 $73.89 2.7%
88313 – TC Special stains group 2 $59.38 $61.29 3.2%
88313 – 26 Special stains group 2 $12.60 $12.62 .2%
88341 – Global Immunohistochemistry (additional stain) $94.65 $98.78 4.4%
88341 – TC Immunohistochemistry (additional stain) $64.78 $69.22 6.9%
88341 – 26 Immunohistochemistry (additional stain) $29.87 $29.56 -1%
88367 – Global Insitu hybridization auto $109.40 $108.15 -1.1%
88367 – TC Insitu hybridization auto $73.06 $72.46 -.8%
88367 – 26 Insitu hybridization auto $36.35 $35.69 -1.8%
88368 – Global Insitu hybridization manual $123.45 $125.81 1.9%
88368 – TC Insitu hybridization manual $79.90 $82.55 3.3%
88368 – 26 Insitu hybridization manual $43.55 $42.26 -3%
G0416 – Global Prostate biopsy $434.40 $384.29 -11.5%
G0416 – TC Prostate biopsy $247.61 $200.80 -18.9%
G0416 – 26 Prostate biopsy $186.79 $183.49 -1.8%

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