UPDATE: BY DECEMBER 2017, MOLDX HAD TAKEN DOWN
ITS SPECIAL TIER 2 GENE BY GENE PRICES.
IT WILL PROBABLY USE
FLAT PAMA PRICES FOR TIER TWO IN 2018.
When the new genetic test coding system was created in CPT Year 2012, and first used by CMS in CY2013 for gapfilling finalized at the end of 2013, a new coding concept called Tier 2 codes were introduced. These are CPT codes for nine "levels" of analysis complexity. Each CPT code in the series 81400,81401, 81402...81408 has a long list of gene names associated with it. Work levels progress from one exon, to two exons, to three or four exons, and so on.
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.
- This seems best aligned with the MolDX statement of work, which is only to price codes which "do not have CLFS prices," and the Tier 2 codes will have CLFS prices. SOW here.
- 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.
- This is the "make crazy" option but they have been very liberal with local usage of Unlisted Code in the past.
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.