Pathology/Lab Coding Alert

Payment unknowns turn to grim predictions for molecular labs.

It’s anybody’s guess how much you’ll get paid when you bill Medicare for CPT^® Tier 1 and Tier 2 molecular pathology codes 81200-81479. But early pricing recommendations from two Medicare Administrative Contractors (MACs) doesn’t look promising.

Look ahead: Because CMS determined to pay for molecular pathology tests on the Clinical Laboratory Fee Schedule (CLFS) using gap-fill methodology, you’ll find the codes currently listed with a $0 value. But the agency plans to assign pricing according to the following schedule:

April 1 — MACs should post local payment amounts

60-day comment period

September 30 — CMS to post final gap-fill payment amounts

30-day reconsideration request period

January 1, 2014 — enact final gap-fill pricing.

See How 2 MACs Weigh In

Ahead of the April 1 deadline, Cahaba and Palmetto GBA recently announced pricing for at least some Tier 1 molecular pathology codes.

Look at the following sample of a few molecular pathology tests to see how payment stacks up between the two payers:

You can compare these fees to what you’ve been charging using the now-deleted CPT^® stacking codes (83890-83914, Molecular diagnostics …). Some sources report that the Cahaba and Palmetto GBA amounts may represent a payment reduction of more than 50 percent, in some cases.

Back story: Some commentators at the CMS 2012 annual public meeting for CLFS pricing of new CPT^® codes cautioned against such changes. Replacing the stacking codes with new Tier 1 and Tier 2 molecular pathology codes "is basically a change of code descriptions," stated Peter Kazon at the meeting, representing the American Clinical Laboratory Association (ACLA). CMS should not take it as an opportunity "to do a wholesale reexamination of pricing for these tests," he said.

For that reason, ACLA recommended that "CMS crosswalk the molecular pathology codes to a fair weighted median price based on historical pricing of the tests using stacking codes," according to Alan Mertz, ACLA president, in a letter to CMS.

Keep up with pricing: Despite such cautions, CMS is moving ahead with gap-fill pricing, and you need to stay informed so you’ll be ready during the comment period. You’ll find a handy tool at www.codemap.com developed by Charles B. Root, PhD, president of CodeMap, a laboratory coding and reimbursement consulting company in Schaumburg, Il.

In addition to finding payment amounts from MACs posted at the CodeMap website as they’re announced, clinical labs can post their own Medicare payment amounts for molecular test claims that they’ve processed.

"The website is designed to provide a means for sharing Medicare payment information for gap-filled molecular pathology procedures," Root says.

What You Should Do Now

The CLFS currently lists $0 for the molecular pathology codes, and CMS ceased payment for deleted CPT^® deleted stacking codes as of January 1. If you’re currently performing molecular pathology tests, what amount should you bill payers and charge clients while you await Medicare’s final gap-fill payment decision?

You should probably continue to bill as you did last year.

"Since contractors are supposed to base their payments on existing and previous charges, it makes sense to maintain the same pricing as last year - at least until some firm knowledge is obtained about where 2013 pricing is going to end up," Root says.