Pathology/Lab Coding Alert

Learn how ADLTs are different.

The vast majority of codes paid on the Clinical Laboratory Fee Schedule (CLFS) adhere to the pricing determinations described in "Grasp Final CLFS Pricing Details for Your Lab" on page 9.

But you still need to understand the three cases that aren't subject to adjusted weighted-mean valuations, as follows.

New 2018 Codes and Beyond

CMS has a long-established procedure for pricing new codes each year, and that process doesn't change. The agency presents the new codes at an annual public meeting in July of each year and invites stakeholder comments about pricing.

Then CMS determines the basis of payment for the new codes using comments from the meeting, according to CMS's Glenn McGuirk, speaking at the 2017 event. The agency issues a final payment determination to either crosswalk the price to existing codes that use similar methods and resources, or gapfill, which involves gathering payment data over the course of a year before setting a rate.

The following represent the final pricing determinations for a few of the new CPT^® 2018 codes (short descriptor in parentheses):

• 81105-81112 (HPA typing) crosswalk each to 81376 (HLA class II typing...): $150.89
• HBB variants for sickle cell anemia 

            o 81361 (common variants) crosswalk to 81227 (CYP2C9 common variants): $174.81
            o 81362 (familial variants) crosswalk to 81215 (BRCA1 familial variants): $375.25
            o 81363 (duplication/deletion) crosswalk to 81294 (MLH1 duplication/deletion): $202.40
            o 81364 (full gene sequence) crosswalk to 81235 (EGFR common variants): $324.58

• 81448 (hereditary peripheral neuropathies) crosswalk to 81435 (Hereditary colon cancer disorders): $722.10
• 81520 (breast cancer recurrence risk) crosswalk to 0008M (former code, same test): $3099.02
• 87662 (Zika detection, amplified probe) crosswalk to 87501 (influenza detection, amplified probe): $63.35.

You can expect this process to continue each year to establish pricing for new codes.

Codes with No Collected Data

CMS was unable to collect pricing data on 67 CLFS codes, many of which were new codes in 2017 that did not have data available for the 2016 data-collection period.

CMS had made a crosswalk determination for most of these codes during the comment process in 2016, and the agency used the same crosswalks to determine pricing for 2018. The following table illustrates some of these codes and payment rates:

Check Out ADLT Pricing

Lab tests classified as Advanced Diagnostic Laboratory Tests (ADLTs) undergo a different procedure to establish pricing.

What it is: An ADLT is a clinical lab test that meets the following criteria:

• Furnished by a single lab
• Analyzes RNA, DNA, and/or proteins, combined with a unique algorithm to arrive at a single result
• Cleared by the U.S. Food and Drug Administration (FDA) OR
• Other criteria, such as a test that provides new clinical diagnostic information the lab can't provide from any other test or combination of tests.

Pricing: CMS will pay the actual list charge, which is the "publically available rate on the first day a new ADLT is [available]" for three calendar quarters. Once the initial period passes, CMS will base the ADLT price on the weighted median of the private payer rate paid to the single lab that performs the test.

Rather than follow the three-year cycle for collecting payment data for these tests, CMS will update ADLT payment rates annually, based on the weighted median of the private payer rates for the test.