Pathology/Lab Coding Alert

Check out the CMS gap-fill amounts with comment period.

A fog just lifted on the mystery surrounding Medicare payment rates for CPT^® Tier 1 and Tier 2 molecular pathology codes 81200-81479. If your lab is one of many that hasn’t been paid for molecular testing performed since Jan. 1, CMS’s recent announcement may unlock MAC payment for these services. 

CMS notice: Based on gapfill payment methodology, CMS published interim pricing and rationale from Medicare administrative contractors (MACs) on May 9 for molecular pathology codes. The CMS notice marks the start of a 60-day comment period that you can use to impact final pricing for molecular pathology services.

Inspect MAC Payment Recommendations

One peek at the CMS interim pricing report shows a wide variability between MACS, and pricing that is generally much lower than what labs have been getting using the now-deleted CPT^® stacking codes (83890-83914, Molecular diagnostics…). See Table 1 for some interim pricing examples.

Indiscriminate payment change: At the CMS 2012 annual public meeting for CLFS pricing of new CPT^® codes, some commentators warned of potential molecular pathology pricing upheaval with gap-filling.

Replacing the stacking codes with new Tier 1 and Tier 2 molecular pathology codes “is basically a change of code descriptions,” Peter Kazon pointed out, representing the American Clinical Laboratory Association (ACLA) at the meeting. CMS should not take it as an opportunity “to do a wholesale reexamination of pricing for these tests,” he cautioned.

That’s why the 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.

However, the CMS is proceeding with pricing based on gapfilling, which uses payment rates set by MACs as the starting point.

Rationale lacking: Although CMS expected contractors to provide rationale for their pricing, most did not do so. Of the MACs reporting rationale, most designated only why specific codes are not covered, using general comments such as “not medically necessary,” or “investigational.”

Table 1:

Look to Gapfill Path Ahead

With the decision to pay for molecular pathology tests on the Clinical Laboratory Fee Schedule (CLFS) using gapfill rather than crosswalk methodology, CMS initiated the payment determination process by directing MACs to post local payment amounts by April 1, 2013.

Although certain individual MACS had previously released interim prices, CMS published pricing for all reporting MACS in the May 9 memo available at www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/ClinicalLabFeeSched/Gapfill-Pricing-Inquiries.html. You can also find the pricing rationale and instructions for commenting on pricing at this link.

Upcoming schedule: After reviewing comments from the 60-day period with MACs, CMS expects to release final molecular pathology pricing in Sept., 2013. “These prices will be used to pay for [molecular pathology] test codes in 2013 and 2014,” CMS states. Following the pricing announcement, you’ll have an additional 30 days to file a “reconsideration request” (CMS will post instructions at that time).