07/11/2014

Summary of Calendar Year 2015 Physician Fee Schedule (PFS) Proposed Rule

Summary of Calendar Year 2015 Physician Fee Schedule (PFS) Proposed Rule


This is a review of the provisions in the 2015 Physician Fee Schedule (PFS) Proposed Rule that was published in the Federal Register on July 11, 2014. If you wish to comment on the PFS proposed rule, submit your comments by September 2, 2014. If you do submit comments, please forward a copy of your comments to the NILA office.

Technological Review of CLFS

As mentioned in our email dated July 8, 2014, the proposed PFS rule does not propose to revise Part B Clinical Laboratory Fee Schedule (CLFS) payment rates in 2015 and 2016 based on technological changes because of the Protecting Access to Medicare Act (PAMA). Instead, CMS will establish a separate rulemaking process to establish parameters for the collection of private payor rates in 2016 and a new payment assessment process in accordance with PAMA, with revised payment rates beginning in 2017.

Local Coverage Determination (LCD) Process

The proposed PFS rule outlines a revised process for Local Coverage Determinations (LCDs) for clinical diagnostic laboratory tests published on or after January 1, 2015.  CMS’s process includes a review of the current LCD process, an analysis of the ongoing pilot project that CMS launched with Palmetto GBA, and addressing the requirements set forth in PAMA.

While the CMS/Palmetto GBA pilot project was focused only on molecular diagnostics, CMS is proposing that the new LCD process apply to ALL clinical diagnostic laboratory tests.  CMS claims it wants to ensure that diagnostic tests actually perform as expected and that they improve clinical care. Additionally, CMS says it has an ongoing “responsibility to ensure that appropriate tests are covered by Medicare and that coverage is limited to tests for which the test results are used by the ordering physician in the management of the beneficiary’s specific medical problem.”

Below is a table in the proposed PFS rule outlining the differences between the current LCD process and CMS’s new proposed process.

Comparison of Current LCD Process versus Proposed LCD Process for Clinical Diagnostic Laboratory Tests Published On Or After January 1, 2015

 
Current LCD Process   Proposed LCD Process for Diagnostic Laboratory Tests
Issue Draft LCD in Medicare Coverage Database, which identifies criteria used for determining coverage under statutory “reasonable and necessary” standard Issue Draft LCD in Medicare Coverage Database, which identifies criteria used for determining coverage under statutory “reasonable and necessary” standard
Public comment period of 45 calendar days Public comment period of 30 calendar days with option to extend
Present LCD at CAC & discussion at open stakeholder meetings Optional CAC meeting. No requirement for open stakeholder meeting
Publication of Comment/Response Document and final LCD (no specified time of publication after the close of the comment period) Publication of Comment/Response Document and final LCD within 45 calendar days of the close of the draft LCD comment period
Notice period of 45 calendar days with the final LCD effective the 46th calendar day Final LCD effective on the date of publication
Interested parties may request reconsideration of an LCD Interested parties may request reconsideration of an LCD
An aggrieved party may further challenge an LCD An aggrieved party may further challenge an LCD

 

Of note when comparing the current LCD process to the proposed LCD process is the following:

  • There will be a shortened period for public comments once a proposed LCD is published from 45 to 30 days.
  • It is possible that no meetings will be held for discussion with stakeholders.
  • CMS will publish comments in response to stakeholder feedback and final LCDs within 45 days after the comment period closes, and there had previously been no set time period for CMS to issue its response.
  • No recommendations are made to improve upon the transparency of how CMS makes final LCD decisions or the data associated with those the decisions.
  • No adjustment is made to the reconsideration or challenge process when a laboratory disagrees with a LCD decision(s).  

CMS’s proposed process does NOT apply to LCDs that are being revised for the following reasons: liberalizing an existing LCD; being issued for a compelling reason; making a non-substantive correction; providing a clarification; making a non-discretionary coverage or diagnosis coding update; making a discretionary coding update that does not restrict; or revising to effectuate an Administrative Law Judge’s decision on a Benefits Improvement and Protection Act (BIPA) Section 522 challenge.  

Misvalued Codes

PAMA expanded the categories of services that HHS is directed to examine for the purpose of identifying potentially misvalued codes. The nine new categories, a number of which do not apply to clinical laboratories, are as follows:

  • Codes that account for the majority of spending under the Physician Fee Schedule (PFS).
  • Codes for services that have experienced a substantial change in the hospital length of stay or procedure time.
  • Codes for which there may be a change in the typical site of service since the code was last valued.
  • Codes for which there is a significant difference in payment for the same service between different sites of service.
  • Codes for which there may be anomalies in relative values within a family of codes.
  • Codes for services where there may be efficiencies when a service is furnished at the same time as other services.
  • Codes with high intra-service work per unit of time.
  • Codes with high PE RVUs.
  • Codes with high cost supplies.  

The proposed rule includes a listing of codes that CMS determines are potentially misvalued codes.  Included in this code list are:  55700 Biopsy of Prostate and 88185 Flowcytometry/tc add-on.

Review the clinical laboratory provisions in the proposed 2015 Physician Fee Schedule Rule as published in the July 11, 2014, Federal Register by clicking the links below. Comments are due by September 2, 2014.

Clinical Laboratory Fee Schedule Provisions (excerpts from entire rule):

Clinical Laboratory Fee Schedule excerpt from the proposed 2015 Physician Fee Schedule Rule (pg. 40376)

Local Coverage Determination Process for Clinical Diagnostic Laboratory Testing excerpt from the proposed 2015 Physician Fee Schedule Rule (pgs. 40378-40380)

Prostate Biopsy Codes--HCPCS Codes G0416, G0417, G0418, and G0419 (pgs. 40340-40341)

Entire Rule (224 pages):

2015 Physician Fee Schedule Proposed Rule

 

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