Wednesday, September 22, 2021

Big News: CMS Posts Proposed Lab Prices for CY2022 New Codes

Every summer, CMS holds meetings on "how to price" new laboratory codes, and each September, CMS releases its actual proposed prices.  Those proposed prices are posted today.

CMS also issued final gapfill prices today, which I handle in a separate blog here.

How To Find the Prices

Here's the web page for lab pricing policy:

https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/ClinicalLabFeeSched/Laboratory_Public_Meetings

Scroll down to PAYMENT DETERMINATIONS and find, CY 2022 - Preliminary Payment Determinations.  CMS's excel spreadsheet will come inside a Zip file.

I've also put a Google Sheets version of the spreadsheet in an open access cloud file here.

Separately, on the web page for the lab pricing expert panel - the PAMA Advisory Panel on Clinical Diagnostic Laboratory Tests - CMS has posted the Panel recommendations they voted on July 28-29, 2021.  

Just scroll down for "Panel Recommendations"and find "Recommendations...July 28-29, 2021".  It's a fine-print 9-page PDF.  Highlights of the panel votes are also within column G of the proposed pricing spreadsheet.  

https://www.cms.gov/Regulations-and-Guidance/Guidance/FACA/AdvisoryPanelonClinicalDiagnosticLaboratoryTests

"CMS Disagrees"

99 codes are being priced.  CMS flags where its pricing disagrees with the majority vote of the PAMA panel.  Using a quick tally with the "search word" function, I see 39 + 16 or 57 disagreements between CMS and the panel.  This is higher than typical.  Note that 39 are filed as "disagrees with panel" entirely, and 16 are filed as "agrees with MINORITY recommendation" of panel.  (Glass half full...)

In some cases CMS changes the crosswalk. For example, 860X2 (aquaphorin) was panel voted to 86146 $25, but CMS chose 83516 $11.   

Comment to October 21

The top line of the CMS excel spreadsheet informs us that comments will be accepted through October 21, 2021.   It's not unusual for a substantial number of codes to change prices between the September proposal and the November final listing.

Statistics

Of 58 crosswalked codes, all but three were to single target  crosswalks.  Three were to a sum of 2 codes.  No fractions were used.

Only 3 of the 58 crosswalked codes was crosswalked to a PLA code target.  Two of these were crosswalked to 0001U, RBC epitope analysis by DNA (for rare blood group typing).  The third was crosswalked to 0120U, a Mayo RNA panel lymphoma test.

I tallied 40 gapfill codes; that's on par with last year (not far from half).

CMS lists only crosswalk code targets, not their prices or the proposed price.  You have to hunt and peck between this spreadsheet and the price list spreadsheet to dollarize the amounts.

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Occasionally CMS posts updates and numeric error corrections so always check the original CMS websites.

G0327 - CMS had proposed to price G0327, a placeholder code for future tests screening colon cancer by liquid biopsy of blood.   CMS has simply deleted this code without comment.  Stakeholders had objected that the code had missed regulatory deadlines for inclusion and was no appropriate to crosswalk or gapfill, because no such tests have yet been released.

For the September 2019 release event, 9/27/2019, here.

For the September 2020 release event, 9/22/2020, here.  There were 132 agenda items.