Each year, CMS considers all new lab codes in a summer pricing meeting, and CMS sets some quickly by "crosswalk" to an existing price. Others are sent to "gapfill," a process in the second year where MAC medical directors proposed then finalize pricing for the "gapfilled" lab codes.
While CMS sets "gapfill" at the median rate of all the states, MolDx controls pricing in 28 states and therefore sets the next year's median regardless of pricing proposals in the other 22 states.
On October 22, 2020, CMS released final gapfill prices for CY2021 on 37 codes. (I say final; technically the prices can be appealed to CMS administrators til November 22).
- See the public meeting home page here.
- Look near the bottom for the 2021 final gapfill file, it should be here.
- I've made a summary cloud file comparing June proposed and October final on one spreadsheet, here.
CMS revised 4 prices upwards and left 33 the same. Prices on the elevated tests are shown:
CMS had comments to change pricing on 7 codes, acting as requested on 4. CMS turned down 3 requests for higher prices. CMS also logged comments "supporting the proposed price" (no action needed) on 2 codes.