On November 17, 2015, CMS released final decisions on how it will handle new laboratory codes for January, 2016. As has been discussed in several public meetings and public comment periods since July, the new codes enter either a crosswalk or gapfill process. There has been much sturm and drang all year how CMS would handle drug tox coding and pricing. There was a kerfuffle in September when about ten MAAA tests were priced at about $692. Increasing attention has been paid to an AMP proposal to price new codes via a "log natural" method.
Generally, simple genetic codes were crosswalked to existing genes, and complex genomic procedures (and new MAAA tests) were sent to the gap fill process for CY2016. For drug tox results, see below.
At the CLFS "Public Meetings" webpage, here, see the heading, "CLFS Final Determinations for CY 2016 Codes PDF 428 KB" - here.
For drug testing, CMS finalized 3 presumptive testing codes and 4 definitive testing codes. To price these, the 3 presumptive codes were finalized at 0.75 x G0434, 1 x G0434, and 4 x G0434. The definitive testing codes were finalized at [1-7 drug classes] = 2 x 82542 plus five times (25% of 82542); [8-14 drug classes] = 2 x 82542 plus twelve times (25% of 82542); [15-21 classes] = 2 x 82542 plus 19 times (25% of 82542) and finally for >21 classes, 2 x 82542 plus 27 times (25% of 82542). In September, CMS had proposed only 10% as the multiplier for the large volume tests.
Generally, simple genetic codes were crosswalked to existing genes, and complex genomic procedures (and new MAAA tests) were sent to the gap fill process for CY2016.
Chemosensitivity tumor cell culture codes (81535, 81536) were priced by crosswalk to the 88239 and 87900. However, CMS noted it came up with this idea after the comment process, so it is considering further public comment. Some MACs have non coverage LCDs on this type of test.