Pathology sees 9% cut in 2021 MPFS Final Rule

December 2, 2020

After a lengthy delay, CMS released the 2021 Medicare Physician Fee Schedule Final Rule Tuesday. It finalizes several telehealth flexibilities introduced during the public health emergency while also significantly overhauling reimbursements for evaluation and management (E/M) services.

Unfortunately, the rule still contains significant cuts for procedure-heavy specialties such as pathology and radiology in order to offset boosts for E/M payments. The conversion factor is $32.41, which is a whopping decrease of $3.68 from the 2020 MPFS conversion factor of $36.09. Pathology and Independent Labs are expected to see overall reimbursement cuts of 9% and 5%, respectively, while radiology will experience a 10% cut.

SpecialtyAllowed Charges (mil)Impact of Work RVU ChangesImpact of PE RVU ChangeImpact of PE RVU ChangeCombined Impact
Source: CMS

There is legislation pending in Congress (HR 8702) that requests a 1-year exemption from MPFS budget neutrality requirements, however, passage is not imminent at this time. Currently, Vachette is moving forward assuming these cuts will remain in place. RVU data for individual codes has not yet been published, but we will provide further analysis on rate changes once that data is made available.

CPT CodeFinal 2021Current 2020% Change
88112 – Global$63.52$68.57-7.4%
88112 – TC$37.92$39.70-4.5%
88112 – 26$25.60$28.87-11.3%
88120 – Global$604.12$589.342.5%
88120 – TC$550.00$529.074.0%
88120 – 26$54.12$60.27-10.2%
88121 – Global$434.94$450.40-3.4%
88121 – TC$390.22$399.51-2.3%
88121 – 26$44.73$50.89-12.1%
88305 – Global$66.76$71.46-6.6%
88305 – TC$32.09$32.12-0.1%
88305 – 26$34.68$39.34-11.8%
88307 – Global $272.89$281.50-3.1%
88307 – TC$196.40$194.880.8%
88307 – 26$76.49$86.62-11.7%
88309 – Global$414.52$427.66-3.1%
88309 – TC$279.37$275.001.6%
88309 – 26$135.15$152.66-11.5%
88312 – Global$106.63$107.19-0.5%
88312 – TC$82.00$79.403.3%
88312 – 26$24.63$27.79-11.4%
88313 – Global$77.46$77.230.3%
88313 – TC$66.12$64.602.4%
88313 – 26$11.34$12.63-10.2%
88341 – Global$88.80$94.19-5.7%
88341 – TC$62.55$64.60-3.2%
88341 – 26$26.25$29.59-11.3%
88367 – Global$109.87$115.13-4.6%
88367 – TC$78.43$79.40-1.2%
88367 – 26$31.44$35.73-12.0%
88368 – Global$129.64$133.89-3.2%
88368 – TC$91.40$90.580.9%
88368 – 26$38.24$43.31-11.7%
G0416 – Global$332.85$347.90-4.3%
G0416 – TC$167.24$162.403.0%
G0416 – 26$165.62$185.50-10.7%
G0452 – Global$46.02N/A 
G0452 – TC$2.92N/A 
G0452 – 26$43.11$19.12125.5%
Source: CMS

Below is a summary of other significant changes for pathologists:

Next PAMA reporting period for CLFS data

CMS announced it is finalizing its proposal to delay the next PAMA private payer data reporting period to Jan. 1-March 31, 2022. Originally, labs were supposed to report private payer data for CDLTs collected between Jan. 1 and June 30 of 2019 in the first quarter of 2020. That deadline was first pushed to 2021 by last year’s LAB Act, and has now been delayed again due to concerns over the administrative burden of reporting during the public health emergency.


  • After the data reporting period in 2022, there is a three-year data reporting cycle for CDLTs that are not ADLTs (that is 2025, 2028, and so on).
  • Additionally, the statutory phase-in of payment reductions is extended through 2024. There is a 0% payment reduction for 2021 as compared to the amount established for 2020. For the 2022 through 2024 payment years, payments may not be reduced by more than 15 percent as compared to the amount established for the preceding year.

Molecular Pathology Interpretations (G0452)

After being identified as potentially mis-valued at the October 2018 RUC meeting, the RUC found that the assumptions regarding work and time for the procedure were last updated in 1995. Based on that review, CMS has finalized a work RVU increase to 0.93, up substantially from the 0.37 RVUs the code was valued at in 2020.

HCPCSDescriptorCY 2020 Work RVUProposed CY 2021 Work RVUFinal CY 2021 Work RVU
G0452Molecular pathology procedure; physician interpretation and report0.370.930.93
Source: CMS

CMS also recognized the technical component of the procedure for the first time. Overall, the code’s total non-facility Global payment will jump to $46.02, a massive 125% increase from the $19.12 CMS reimbursed for the interpretation in 2019.

2021 QPP/MIPS Changes

Pathology Specialty Measure Set:

The six quality measures available to pathologists under their specialty measure set will remain in place for 2021 reporting. They are:

  • Barrett’s Esophagus
  • Radical Prostatectomy
  • Lung Cancer Reporting (Biology/Cytology Specimens)
  • Lung Cancer Reporting (Resection Specimens)
  • Melanoma Reporting
  • Skin Cancer: Biopsy Reporting Time — Pathologist to Clinician

Performance Threshold:

Initially, CMS had proposed to increase the 2021 performance threshold to avoid a penalty to just 50 points, a boost of only 5 points over the 2020 threshold. However, CMS has walked back this proposal and instead will raise the 2021 threshold to 60 points. Given this relatively high bar compared to past years, this may finally be the first year where enough poor performers are penalized to make decent bonuses available to those who successfully report.

Sunsetting of CMS Web Interface:

The 2021 reporting year is the final year that the CMS Web Interface will be made available to groups and individuals as a reporting option.

Category Weighting:

Below are the category weights for traditional MIPS reporting. However, keep in mind that most pathologists are exempt from the Promoting Interoperability and Cost categories due to their status as non-patient facing clinicians. In this event, those categories are reweighted to a clinician’s Quality score.

• The Quality performance category will be weighted at 40% (5% decrease).
• The Cost performance category will be weighted at 20% (5% increase).
• The Promoting Interoperability performance category will be weighted at 25% (no change).
• The Improvement Activities performance category will be weighted at 15% (no change).

If you have questions about how your group or lab may be impacted by these changes, feel free to contact us at 517-486-4262.

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