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2021 Physician Fee Schedule Poses “Major Threat to Pathology”

2021 Physician Fee Schedule Poses “Major Threat to Pathology”

On August 4, 2020, Centers for Medicare & Medicaid Services (CMS) released its 2021 Physician Fee Schedule and ASCP has labeled it a “major threat to pathology” because of the significant cuts in payments for pathologists and clinical laboratories, especially the professional component.

CMS is projecting a 9% overall cut in payments to pathologists, which will total $1.1 billion over 10 years, largely due to the Agency’s proposal to increase payment rates for evaluation and management (E/M) services which is an area that has been heavily utilized during the COVID-19 pandemic and also made necessary by an 11% reduction in the Medicare conversion factor.

Due to budget neutrality requirements, increases in payments for one area of service require offsetting cuts elsewhere. For 2021, these cuts have been mainly allocated among pathologists, cardiologists, and radiologists.

ASCP’s position is that these cuts could weaken the ability of pathologists and clinical laboratories to meet patient testing needs for COVID-19 and other diseases and conditions. Several pathology organizations are making an effort to persuade HHS and Congress to waive the budget neutrality requirements, which would allow the CMS to allocate funds to an area of need without it being at the expense of other physicians who may be experiencing the same or higher volumes of patients than they did the year before.

Below are the fee schedule changes for pathology codes effective next year. This is not finalized yet, but we expect something very close to this on Jan 1, 2021. While the overall reduction was 9%, the 26 modifier professional component reduction was nearly 12% while global saw an average of 3.6% reduction and the technical component was largely unaffected overall.

Of course, the utilization of these codes in your practice will determine the overall impact on your 2021 revenue, but some level of revenue reduction is a certainty. Typically 88305, 88307, 88309, and 88341 make up about two thirds of billed charges for most professional component pathology practices, and Medicare payments are generally one third of revenue. So unless your practice is different than a typical pathology group, these cuts will have a significant bearing on pathology revenue.

For help formulating a plan for your 2021 revenue cycle, schedule time to talk to us, the Pathology RCM and Practice Management experts.

2021 Proposed Patholgy Reimbursement versus Current 2020

CPT CodeServiceProposed 2021Current 2020% Change
88112 – GlobalCytopath cell enhance tech$63.55$68.57-7.3%
88112 – TCCytopath cell enhance tech$38.07$39.70-4.1%
88112 – 26Cytopath cell enhance tech$25.49$28.87-11.7%
88120 – GlobalCytp urne 3-5 probes ea spec$601.97$589.342.1%
88120 – TCCytp urne 3-5 probes ea spec$548.10$529.073.6%
88120 – 26Cytp urne 3-5 probes ea spec$53.87$60.27-10.6%
88121 – GlobalCytp urine 3-5 probes cmptr$433.25$450.40-3.8%
88121 – TCCytp urine 3-5 probes cmptr$388.73$399.51-2.7%
88121 – 26Cytp urine 3-5 probes cmptr$44.52$50.89-12.5%
88184Flowcytometry/ 1st marker$66.78$68.21-2.1%
88185Flowcytometry/ additional marker$21.94$22.38-2.0%
88187Flowcytometry/read 2-8$33.87$39.34-13.9%
88188Flowcytometry/read 9-15$58.71$66.04-11.1%
88189Flowcytometry/ read 16+$78.39$88.78-11.7%
88305- GlobalTissue exam by pathologist$66.78$71.46-6.5%
88305 – TCTissue exam by pathologist$32.26$32.120.4%
88305 – 26Tissue exam by pathologist$34.52$39.34-12.3%
88307 – GlobalLevel V, tissue exam by pathologist$271.95$281.50-3.4%
88307 – TCLevel V, tissue exam by pathologist$195.82$194.880.5%
88307 – 26Level V, tissue exam by pathologist$76.13$86.62-12.1%
88309 – GlobalTissue exam by pathologist$412.93$427.66-3.4%
88309 – TCTissue exam by pathologist$278.40$275.001.2%
88309 – 26Tissue exam by pathologist$134.52$152.66-11.9%
88312 – GlobalSpecial stains group 1$106.14$107.19-1.0%
88312 – TCSpecial stains group 1$81.62$79.402.8%
88312 – 26Special stains group 1$24.52$27.79-11.8%
88313 – GlobalSpecial stains group 2$77.10$77.23-0.2%
88313 – TCSpecial stains group 2$65.81$64.601.9%
88313 – 26Special stains group 2$11.29$12.63-10.6%
88341 – GlobalImmunohistochemistry (add stain)$88.07$94.19-6.5%
88341 – TCImmunohistochemistry (add stain)$61.94$64.60-4.1%
88341 – 26Immunohistochemistry (add stain)$26.13$29.59-11.7%
88367 – GlobalInsitu hybridization auto$109.68$115.13-4.7%
88367 – TCInsitu hybridization auto$78.39$79.40-1.3%
88367 – 26Insitu hybridization auto$31.29$35.73-12.4%
88368 – GlobalInsitu hybridization manual$129.36$133.89-3.4%
88368 – TCInsitu hybridization manual$91.30$90.580.8%
88368 – 26Insitu hybridization manual$38.06$43.31-12.1%
G0416 – GlobalProstate biopsy$331.31$347.90-4.8%
G0416 – TCProstate biopsy$166.46$162.402.5%
G0416 – 26Prostate biopsy$164.85$185.50-11.1%

Written by Andy Harner, Vice President of Client Services

Pathology Billing Company

Andy oversees Medusind’s Virginia-based service delivery for pathology organizations.

His team, like all of Medusind, delivers outstanding practice performance, streamlines the collection and reporting of quality data, and helps pathology organizations achieve their business goals, big or small.

Get a quote or learn more about Medusind’s Pathology Billing and Practice Management solutions.