MolDx provides a table of meticulously determined individual prices for each single one of the covered genes under Tier 2. (Most genes listed in the AMA Tier 2 set are not covered by MolDx). See the June, 2017 version of this fee schedule here or in the cloud here. Like snowflakes, almost all are different (there are 7 pairs of matching prices among 49 genes, or 42 prices for 49 genes.)
Through PAMA, CMS has set rates for each Tier 2 code to be effective on January 1, 2018. The second-to-right column, "Pmt", is the new 2018 PAMA rate. The "Ave Pmt" column is the observed average payment rate at CMS during 2016.
Here's a brain teaser for MolDx watchers. What will MolDx do when these fixed fee rates become effective?
- MolDx trashes its elaborate special Tier 2 fee schedule series and just uses the new Tier 2 codes.
- This is the obvious choice; it's what non-MolDx MACs will do.
- MolDx could require the Tier 2 codes to be used with "reduced services" or "enhanced services" modifiers tagged to Z codes and continue to offer special pricing lower or higher than the official Tier 2 code price.
- MolDX could not recognize the Tier 2 codes and throw all the services onto unlisted codes matched with Z codes.
I think the answer will be #1, and the snowflake-like pricing of Tier 2 codes will be tossed overboard, but if it is #2 or #3 you heard it here first.