In This Issue...

CMS Proposes to Review All Lab Codes for Overpayments

The Centers for Medicare and Medicaid Services released a proposed rule, the Medicare Program; Revisions to Payment Policies under the Physician Fee Schedule, Clinical Laboratory Fee Schedule & Other Revisions to Part B for CY 2014 (CMS-1600-P), that would give the agency authority to review every laboratory CPT code to determine whether advances in technology have reduced costs for performing the test.  The purpose of the initiative would be to identify tests that are overpaid, thus warranting reductions in payments for certain tests.  The agency particularly notes that the development of point-of-care testing technologies, which are smaller, cheaper and provide faster results as a contributing factor.  If the agency moves forward with this proposal, CMS would start with the older tests first gradually reaching the more recently developed tests.  Once fully implemented, every test code would be evaluated on a five year rotation.  Comments are due by September 6th (Go to page 253).

CMS Proposes to Bundle Some Lab Tests in Outpatient PPS

The Centers for Medicare and Medicaid Services released another draft proposed rule, Medicare and Medicaid Programs: Hospital Outpatient Prospective Payment and Ambulatory Surgical Center Payment Systems and Quality Reporting Programs….(CMS-1601-P), that would affect laboratory reimbursement.  The proposal would include “laboratory tests…that are integral, ancillary, supportive, dependent, or adjunctive to the primary services provided in the hospital outpatient setting” as part of a single outpatient prospective payment.   To be included, the test would have to be ordered on the same date of care, by the same physician and be related to the primary service.  Molecular tests would be excluded from this proposal.  Laboratory tests not included in this approach would still be paid under the clinical laboratory fee schedule.  Comments are due by September 6th.  (Go to page 171).

USPSTF Recommends One-time HCV Screening

The United States Preventive Services Task Force (USPSTF) released a recommendation regarding who should be screened for the hepatitis C virus, which is a leading cause of liver damage and liver cancer in the United States.  The CDC estimates that approximately 15,000 people die annually from hepatitis C-related liver disease.  The USPSTF is recommending that all people who have or are engaging in risky behavior be tested.  In addition the preventive task force is recommending that all adults born between 1945 and 1965 have a one-time screening test for the hepatitis C virus.  According to the expert panel, 75 percent of those individuals identified with hepatitis C are baby boomers and many are asymptomatic.  A copy of the USPSTF assessment and recommendation is on the agency website.

Lawmakers Request CMS Meet With Stakeholders Regarding Molecular Codes

A group of 27 Members of the House of Representatives, spearheaded by Reps. Michael Burgess (R-TX) and Bill Pascrell (D-NJ) wrote to the Centers for Medicare and Medicaid Services (CMS) requesting that the agency meet with stakeholders to discuss concerns involving the use of the gap-filling process in setting the new molecular pathology fees.  Although the legislators agree with CMS’s shift from stacking codes to individual CPT codes for the molecular tests, they echoed many of the concerns raised by the laboratory community regarding the current process, such as:

  • the lack of transparency in setting the new fees;
  • the failure of some contractors to pay molecular claims; and
  • the proposed fees for some tests being below the cost of performing it.

The bipartisan group is urging CMS to hold an open forum specifically on molecular reimbursement.  The lawmakers are also suggesting that CMS “require” the contractors to “remit reimbursement as soon as feasible” to laboratories that have performed tests but not yet been paid.  A draft of the congressional letter is available on the ACLA website.