- On the CMS CLFS webpage here, see the final "2018 Final Gapfill Determinations."
CMS provided summary rationales for each price. MACs varied more from one another in the final price proposals than in the preliminary ones in June; the final price is set by the median, which is controlled by MolDx-system MACs which essentially acts as a voting bloc of 30 states.
Most of the codes being gapfilled were either "PLA" (new rapid) codes, ending in "U" such as 0001U, or administrative MAAA codes (ending in M, such as 0001M). See table below.
Whole Genome Analysis
The biggest price change was for whole genome analysis (81425), sibling/family member analysis (81426), and reanalysis (81427). These rose from a uniform price of $349 (?!) to $5031, $2709, and $2337, respectively. (Over 20 comments letters were submitted to CMS, if I can summarize, generally portraying the $349 price as ridiculous.) The whole genome price of $5031 is a little higher than the whole exome price of $4780, as set by market rates under PAMA. Use of these tests is likely to be rare in the Medicare population but a growing literature has documented the usefulness of whole genome in special cases including gravely ill newborns.
How the MACs priced WGS-related codes is shown in the next table. By my count, 32 MolDx-related CLFS zones proposed $5031 for 81425. Novitas and FCSO had 14 zones, at $4780. NGS MAC had 12 zones at $349. See table:
|click to enlarge|
Disclosure: I served as a consultant this summer to several entities working to raise the median price from the initial $349 to $5000 or better.
See the original CMS spreadsheet at the link early in the blog. I've put a slightly tricked-out Excel with highlighted tabs for short summary views and comments views in the cloud, here.
MAC rationales for 81425, 81426 were stated to be:
Some contractors based initial recommendations on laboratories with similar test with charges of $349.00. Upon further review, however, several contractors revised their recommendations. Some contractors looked to similar tests on the CLFS, specifically 81415, a Whole Exome Sequencing code, and adjusted the payment rate based on input from several laboratories. Other contractors simply followed public recommendations to use CPT 81415 as a similar test on the CLFS to recommend a payment rate.
Initially, several contractors felt this code represented interpretation only and thus averaged two comparable codes (G0452-26 and 88291). Upon further review, some contractors followed public recommendations to use CPT 81417 as a similar test on the CLFS. Others did not recommend this similar payment rate and instead estimated a professional labor rates for the code.
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