FISH Payment Cut for 2015 Under Medicare; IHC Code 88342 Resurrected

The final Physician Fee Schedule (PFS) for 2015, released on Halloween, contains good news and bad news for clinical and anatomic pathologists. First the good news: The Centers for Medicare and Medicaid Services (CMS) has resurrected CPT 88342 for immunohistochemistry (IHC) and killed the two G codes (G0461 and G0462) that it had put into place for 2014. Two new IHC codes, 88341 and 88344, have been introduced. Now the bad news: Medicare payment for fluorescent in situ hybridization (FISH) testing in 2015 will drop significantly despite an earlier proposal by the CMS to increase FISH payment by 30 percent. While payments for some pathology services considered overvalued are adjusted downward, some others will see payment increases. The net change, says the College of American Pathologists (CAP), is 0 percent. Details of the final PFS rule for 2015 are detailed below: FISH Testing CMS has revised both codes and payments used for FISH testing. First, it revised codes 88365, 88367, and 88368 to specify “each separately identifiable probe per block.” It also created six new codes, three of which apply to add-on FISH services (88364, 88373, and 88369) and three of which apply to multiplex probes (88366, 88374, and 88377). For five of the FISH codes, CMS established relative units that were lower than what was recommended by the American Medical Association. As a result, payment for the technical component of FISH testing is slated to drop by up to 58 percent in 2015. Immunohistochemistry In recent years, CMS targeted IHC as overvalued and created G codes in 2014 to reduce Medicare spending in this area. For 2015, CMS has eliminated the G codes and 88343 and has reinstated 88342, immunohistochemistry or immunocytochemistry, per specimen, initial single antibody stain procedure ($90.58). In addition, CMS has introduced two new IHC codes:

• 88341, immunohistochemistry or immunocytochemistry, per specimen, each additional single antibody stain procedure (list separately in addition to code for primary procedure); and
• 88344, immunohistochemistry or immunocytochemistry, per specimen, each multiplex antibody stain procedure.

Prostate G Codes CMS is finalizing its proposal to use a single code, G0416, to cover all prostate needle biopsies regardless of the number of biopsies submitted and to delete three other recently introduced G codes for prostate biopsies. According to the rule, CMS believes that using G0416 to report all prostate biopsy pathology services, regardless of the number of specimens, would simplify the coding and mitigate overutilization incentives. “Given the infrequency with which G0417, G0418, and G0419 are used, we did not believe this was a significant change,” it said. “Based on our review of medical literature and examination of Medicare claims data, we indicated that we believe that the typical number of specimens evaluated for prostate biopsies is between 10 and 12.” For 2015, there will be one payment for prostate biopsy services on Medicare patients using G0416. Medicare will pay $467 for the technical component (TC), $183 for the professional component, and $649 for global payment. CAP opposes this change and plans to work with CMS on its review of payment for this code in 2016. Other Code-Level Changes CMS accepted CAP’s argument to pay for CPT code 88375, which was new in 2014. This code is for endomicroscopy interpretation and represents a reversed decision not to pay separately on the PFS last year. The agency also accepted Relative Value Update Committee-approved values developed by CAP for microdissection (88380 and 88381), which was also targeted. The agency also made cuts to the direct costs used to determine payment for microdissection services. Although payment for the service decreased, there was significant concern that Medicare would take actions to not pay for pathologists’ work associated with the services, as well as the technical costs. LCD Changes CMS had sought to expand the Palmetto Molecular Diagnostic Service program (MolDx) for all local coverage determinations (LCDs) for clinical diagnostic laboratory tests. The new process would have shortened the public comment period from 45 days to 30 and limited the opportunities for stakeholders to suggest improvements to draft LCDs based upon their knowledge of the medical literature and local practice patterns. The number of Medicare contractors also would have been reduced as required by the Protecting Access to Medicare Act of 2014. CMS says it will not move forward with the LCD proposal through this rulemaking and will explore the possibility of future notice and comment on this issue. New PQRS Measures CMS added three new pathology measures under its Physician Quality Reporting System:

• Lung Cancer Reporting (Biopsy/Cytology Specimens): Pathology reports based on biopsy or cytology specimens with a diagnosis of primary non-small cell lung cancer classified into specific histologic type or classified as NSCLC-NOS with an explanation included in the pathology report.
• Lung Cancer Reporting (Resection Specimens): Pathology reports based on resection specimens with a diagnosis of primary lung carcinoma that include the pT category, pN category, and for non-small cell lung cancer, histologic type.
• Melanoma Reporting: Pathology reports for primary malignant cutaneous melanoma that include the pT category and a statement on thickness and ulceration and for pT1, mitotic rate.

Targeted Codes for Revaluation in 2016 Fee Schedule The 2015 final rule requested that several pathology services may be overvalued and need additional review next year. These include cytopathology interpretation services, the TC payment for flow cytometry, and the Medicare G code for reporting all prostate biopsy specimens. Physician Payment Under the final PFS, Medicare payment for physicians is slated to be reduced by 21.2 percent after March 2015, but the chances that such a cut will actually take effect are slim. The cut is required under the Sustainable Growth Rate (SGR) formula but has been overturned repeatedly by Congress in short-term “doc fixes.” The Protecting Access to Medicare Act of 2014, signed into law in April, provides for no reduction in physician pay furnished through March 2015. Pay for physician services is multiplied by the fixed-dollar conversion factor. The conversion factor for Jan. 1, 2015, through March 31, 2015, will be $35.8013. Absent intervention by Congress, the conversion factor will drop to $28.2239 for the remainder of 2015. Takeaway: The final Physician Fee Schedule for 2015 is a mixed bag for pathologists, though the net effect of payment changes is negligible. Side Box: The 2015 Physician Fee Schedule and supporting documents are available at www.cms.gov. Click on Medicare, and then click on Physician Fee Schedule.