Discoveries in Health Policy

AMA's New Digital Pathology Codes in "Category 3": What If They're Not on the CLFS?

2026-06-07T19:59:36.015-07:00

Key Lesson:In 2026, AMA CPT began assigning whole-slide-imaging digital pathology codes to Category III, rather than the PLA pathway used for earlier WSI codes. That matters because PLA lab codes can move onto the Clinical Laboratory Fee Schedule and be priced by crosswalk or gapfill, while Category III codes are usually not nationally priced by CMS. If software-intensive WSI services

How You Get CMS to Liberalize a Burdensome Rule (Case Study: Physical Therapy Orders)

2026-06-06T16:15:57.928-07:00

Why You May Care... Many stakeholders approach CMS each year with a request to liberalize one or another rule - be it an administrative policy, an NCD, or some other problem. While the example below is not related to molecular laboratories (my main readers), the example DOES show how multiple stakeholders coordinated - and over several years - to get a meaningful policy

CMS Releases Data for "87798" Billing in 2024

2026-06-03T10:27:26.231-07:00

On May 21, 2026, CMS released data by lab and by CPT code (also by physician and CPT code) for Part B payments in CY2024.There's been a lot of discussion of changing payment policies for code 87798 in the past six months; 87798 can be use as a "probe" of the data set.Find more about the data set here:https://www.discoveriesinhealthpolicy.com/2026/06/

Predicting the Scientific Future: From UCSF's Robert Wachter

2026-06-02T17:07:16.045-07:00

Robert Wachter of UCSF is both a medical leader and a futurist. In his newest book, A GIANT LEAP, he discusses AI in medical care. From his early AI experiences in 2022, he extracted the following.The story of whether AI would finally transform healthcare would mostly be about whether the healthcare system could implement these tools in ways that would produce better outcomes for patients,

CMS Releases Rich Cloud Database for CY2024 Claims, Medicare Part B

2026-06-02T10:13:13.112-07:00

If you love CMS Part B data, Christmas comes every May or June, when CMS releases extensive cloud data for all labs and all physician providers of every CPT code. CMS classes this as;Data.cms.gov>> Provider Summary by Type of Service>> Medicare Physician and Other Practitioners [incl labs]Find it here:https://data.cms.gov/provider-summary-by-type-of-service/

A New Commercial Source for Rapid Complete Medicare Claims Research LUMA CLAIMS

2026-06-02T09:22:24.910-07:00

CMS has some free databases for Part B claims - like this one for annual Excel spreadsheets and this one for a cloud database x CPT code x Provider Name. And CMS sells anonymous data files of claims data, too.Now there's a new vender in town. I'll copy below an email I got today about LUMA CLAIMS dot COM. It includes nearly real-time CMS claims processing data (

Using AI: (1) Finding Half-Remembered Papers; (2) Finding Papers of Major Importance. For: Computational Pathology.

2026-05-31T10:57:54.316-07:00

Summary of This Long Post :Creatively Using AI at WorkCase Study: Digital PathologyThis blog begins with an unexpectedly mundane task: finding two important digital pathology papers that I could only half remember. You know the feeling: I recalled the ideas, but not the authors or titles. Using ChatGPT as a research assistant, I tracked down the Dawood paper on confounding and shortcut

A Must-Read Article: Use of Comprehensive Genomic Profiling in Metastatic Cancer of Medicare Beneficiaries

2026-05-30T06:38:03.463-07:00

JAMA Network Open publishes a must-read paper on comprehensive genomic profiling (CGP) by Chow et al. The paper headlines "a difference in Medicare Advantage patients" - less profiling - but the difference is tiny (25% vs 26%!). But there are LARGE differences by geography, and LARGE differences by cancer type.Find it here: https://jamanetwork.com/journals/

NGS MAC Updates LCD in a Few Weeks

2026-05-28T15:11:26.016-07:00

I hear many people complain that it takes years - literally, years - to get updates to LCDs, let alone, consider opening a NEW LCD on some topic.As shown below, the NGS MAC proposed some edits to its molecular LCD in April, the comment period closed on May 16, and the revised LCD was posted on May 28. Including responses to 2 submitted comments.Yay team.______While the CMS name on the

Can AI Write Deep Strategic Business Reports? We Compare Claude and ChatGPT on "Digital Pathology"

2026-05-27T08:44:45.198-07:00

Can AI Write Deep Strategic Business Reports?More and more, I am seeing complex reports automatically generated by Claude Opus 4.7 and by Chat GPT, especially in its "deep research" mode. (I have the $20 subscriptions to each).I gave both AI's a prompt to do a business analysis of two competitors in the digital pathology space (I chose Philips and Roche). Claude Opus took about

How MACs Price Major Services That Lack Fixed RVU's (Case Study: PET CT)

2026-05-26T09:45:00.095-07:00

Header: AMA CPT has created some new Category III codes for whole-slide imaging proprietary tests. However, as of May 26, CMS has NOT added these clinical laboratory codes to the summer CLFS pricing process. What happens to Category III codes in terms of MAC pricing?_____CMS assigns RVU-based national prices to nearly all AMA CPT codes in Category I (aside from clinical

United Healthcare Publishes Variations from "Date of Service" Rule

2026-05-26T07:38:01.647-07:00

Medicare's date of service (DOS) rule for laboratory tests - often given the name, "14 day rule" - gets a new spin in a publication from United Healthcare affecting millions of beneficiaries.Thanks to Ashley Zarling for highlighting the event at LinkedIn.CMS Date of Service. Since about 2001, CMS has set the "date of service" rule for lab tests - both clin lab & pathology - as teh date

Upending the MAC System: Bold Idea Proposed for a Radically Different MAC

2026-05-23T13:25:23.280-07:00

Unhappy with your local MAC? Waiting til you-know-where freezes over before they can issue a new LCD? Anderson/Jackson/Miller have a new proposal to up-end the current A-B MAC system through ongoing, operational competition.https://papers.ssrn.com/sol3/papers.cfm?abstract_id=6624938I've read it; you should read it; it's open access; Claude Opus 4.7 read it, and tells us about it

Dunn Introduces H.R. 8890, Enhanced CLIA - Deja Vu Again

2026-05-20T14:42:05.214-07:00

There have been a few attempts at "Enhanced CLIA" legislation, and there's a new kid in town: H.R. 8890.It's introduced by Congr. Dunn of Florida, who recently introduced an "Improve LCDs" bill (here).The legislative language of H.R. 8890 is NOT posted yet but will appear here.(See page pdf 74 of Congressional Record here.)See early coverage at Genomeweb here. See an article by Alex

Senate Resolution would put Part B Prior Auth (WISeR) on Chopping Block

2026-05-20T11:40:26.415-07:00

HEADER: A new Senate resolution seeks to overturn CMS’s WISeR pilot. This is the CMMI Medicare model that applies AI-supported prior authorization to selected services considered vulnerable to waste or inappropriate use.I wrote about some glitches in WISeR on May 11.Senate Democrats, led by Ron Wyden, Maria Cantwell, Richard Blumenthal, and Kirsten Gillibrand, argue that the model

Augmented AI and AMA Thinking: Wishful Thinking?

2026-05-18T05:08:28.646-07:00

There's a new paper going the rounds of commentary at Linked In:Open access; find it here.See comment at LinkedIn by Jan Beger here. And a view from Robert Lauritzen here. (And see another, related, from Lauritzen, here.)Cuocolo & Huisman are from Italy and the Netherlands; the paper is in European Radiology; the thesis is that many clinicians and policymakers strike the position

Dr Bien-Willner Is Departing MolDx - An Update

2026-05-15T15:52:36.943-07:00

Gabriel Bien-Willner to Transition Out of MolDX Medical Director RoleMay 15, 2025 (Columbia, SC)LinkedIn by GBW: here.Gabriel A. Bien-Willner, MD, PhD, the medical director most closely associated with the modern expansion of Palmetto GBA’s MolDX program, has announced that he will transition out of the MolDX Medical Director role as Palmetto seeks a successor.The move is significant

Digital Pathology Dollars. Re-live the Film-Digital Switchover at the RVU Ranch.

2026-05-14T19:36:18.055-07:00

What’s Past Is Prologue: Medicare, Radiology, and the Strange Migration from Film to Digital##The CMS-RVU migration from film to digital radiology was not simply a technology upgrade; it became a revealing Medicare payment episode. Around 2013–2017, CMS and the AMA/RUC translated the disappearance of film, processors, view boxes, and related supplies into the mechanics of practice

Updated: Amal Thommil's MRD Roadmap

2026-05-14T15:10:49.381-07:00

Amal Thommil of DeciBio updates his map of MRD coverage in oncology.Find it here:https://www.linkedin.com/posts/amalthommil_reimbursement-of-mrd-in-solid-tumors-may-ugcPost-7460780354581303298-xIVG? see original at linked in

AI Guest Column: Chat GPT on TROP2 CDx from Roche Diagnostics Day

2026-05-14T15:01:18.710-07:00

A previous blog summarized the 3-hour, annual Roche Diagnostics Day.I asked Chat GPT to go back to the transcript and discuss the news as far as TROP2 CDx coming through FDA using the AZ QCS technology.As always, take this as an example of the current state of "AI thinking and writing" - not as gospel truth.###Roche’s TROP2 / AstraZeneca CDx StrategyWhy Roche is treating this as more than “

AI Guest Column: ChatGPT & Opus: Roche Diagnostics Day

2026-05-14T14:55:25.960-07:00

On May 12, 2026, Roche held its annual Diagnostics Day with a 3-hour webinar and a 150-slide deck.Find them here: https://www.roche.com/investors/events/diagnostics-day-2026I gave the materials separately to Chat GPT and Opus 4.7, which provided 13p and 24p reports. I asked Chat GPT to produce a single combined report with a cover page (15pp).Remember, this isn't an example of

To Fix Software and AI Reimbursement - Do We Need to Understand the RUC?

2026-05-14T13:53:43.885-07:00

To Fix Software and AI Reimbursement - Do We Need to Understand the RUC?Maybe.For at least five years, CMS has had difficulty pricing software-intensive services like AI. In 2025, CMS included an RFI for "public comment" on these problems in both the July 2025 Physician (Part B) rulemaking and the Hospital Outpatient rulemaking. One Damn Thing After AnotherOne case study was the

Understanding FDA Regulatory Documents for Digital Pathology: PAIGE and ARTERA-AI

2026-05-14T13:32:29.467-07:00

We often hear there are 1000 FDA software/AI devices or SaMD for radiology, and only a few for pathology.Let's look at pathology, and see what the FDA regulatory publications are. We also look at the sometimes-confusing delays and timelines in the appearance of documents.Classification Letter and "Safety and Effectiveness" ReviewFDA issues a clearance or classification letter, reflecting

WISeR Prior Authorization - It's Worse Than We Knew. Case study: DBS in PD.

2026-05-11T13:31:00.000-07:00

Announced last summer, CMS has now instituted the WISeR program to force prior authorization into Medicare Part B using outside venders and their software.There's a new piece about it in JAMA Internal Medicine currently. Kannarkat et al. They note, CMS puts forth a thoughtful effort through WISeR to reduce health care waste....With WISeR, AI tools prescreen PA documentation for

AI Guest Column: Will Genomics Move In-House or to Send-Out?

2026-05-11T08:12:00.000-07:00

Header: For years, one of the Grand Questions in genomics has been "in house versus send out." I asked Claude Opus 4.7 to write a book chapter on how the pro's and con's currently align.As always with "AI Guest Column," the point is not the "answer" but to show us a checkpoint on how AI currently researches data and assembles an argument.####Will new landmark events, like the approval of