Pathology/Lab Coding Alert

CMS indicates CLFS, perhaps some MPFS pay.

The Clinical Lab Fee Schedule (CLFS) is for molecular pathology code payment, according to the CY 2013 CLFS preliminary payment determinations posted by CMS on Aug. 31 (www.cms.gov/ClinicalLabFeeSched/).

With some industry heavy weights recommending payment on the Physician Fee Schedule (PFS), labs have been waiting to see what CMS would do. Now the decision is in -- CMS will use gap-filling to price the codes on the CLFS.

Rewind: CPT® 2012 added 101 new molecular pathology codes, but CMS declined to price the codes for CY 2012 due to "stakeholder debate whether Medicare should pay for the molecular pathology tests under the CLFS or the PFS," according to the agency.

Now CPT® proposes 13 new Tier 1 molecular pathology codes for 2013, as you can see in Table 1. With a greater number of CPT® molecular pathology codes for 2013 and the deletion of stacking codes (83890-83914, Molecular diagnostics ...), CMS's payment decision for molecular pathology couldn't be more crucial.

Watch Gapfill Timeline

Unlike crosswalking a new code to the payment rate of a similar code, which allows CMS to assign a national payment amount before January when new codes become effective, gapfilling takes more time.

Here's the process CMS will follow, and the approximate timeline you can expect for pricing of gap-filled codes:

1. Medicare contractors will develop carrier-specific gap-filled amounts by April 1 of 2013. CMS will post these on the Website and accept comments for 60 days.

2. These amounts will then be finalized on September 30, 2013. CMS will post gap-filled payment amounts on the Website as final, and accept reconsideration requests on the gap-filled payment amounts for 30 days.

3. Once the reconsideration process is completed for a cycle, the determination is final and would not be subject to further reconsideration

Leave Door Open to PFS

Commentators at the CLFS public meeting who stated a preference for molecular pathology payment on the PFS might not be completely disappointed.

CMS states that the gapfilling recommendation applies "ONLY to those Molecular Pathology Procedures that would be paid under the CLFS." The agency goes on to say that, based on comments to the CY 2013 PFS, it may decide "that some of the codes on this list are not clinical diagnostic laboratory test codes."

At least three participants in the lab public meeting stated a preference for placing the codes on the PFS based on professional work: American Society for Histocompatibility and Immunogenetics (ASHI), Association for Molecular Pathology (AMP), and College of American Pathologists (CAP).

"These are exceptionally complex tests, ... and there is important review associated before you release the results for patient care," explained Jeffrey Kant, M.D., representing AMP at the public meeting.

How will you know? When CMS posts the CLFS final payment determinations in November (at the same time as the PFS CY 2013 final rule with comment period), you'll see if any molecular pathology tests are on the PFS instead of the CLFS.