The AMA Updates to Tumor Coding: Now Released by CMS; and PGX Coding

Update: AMA is holding June/July/August workgroups on future changes to tumor coding - here.

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On May 26, 2022, CMS released an upcoding code list (i.e. meeting agenda) for the annual lab meeting in which new codes are priced.  Details here.

Several quarters ago, AMA CPT announced they had updated the codes for tumor gene panel testing, and now, those codes are published by CMS as part of the new code pricing process.  (The codes will also be released by AMA itself in September for the 2023 year code book).

Basically, there have been three codes for cancer genomic testing.  81445 was for 5-50 genes in solid cancers, 81450 for 5-50 genes in hematopoietic cancers, and code 81455 for more than 50 genes in any type of cancer.   CMS data for 81455 has always been pretty squirrelly because some such genomic tests have proprietary codes (e.g. 0037U, Foundation Medicine), and the MolDx program has never recognized 81455 as a payable code, so at MolDx, large tumor gene panels have always been coded as 81479, thwarting efforts to understand their volume and rate of change.

Basically, all three codes morph into code pairs, including the base code revised (81455) and probably added new adjacent codes (e.g. 81456) which will represent RNA only analysis.

81445

81445 previously stated,

Targeted genomic sequence analysis panel, solid organ neoplasm, DNA analysis, and RNA analysis when performed, 5-50 genes (eg, ALK, BRAF, CDKN2A, EGFR, ERBB2, KIT, KRAS, NRAS, MET, PDGFRA, PDGFRB, PGR, PIK3CA, PTEN, RET), interrogation for sequence variants and copy number variants or rearrangements, if performed.

81445 is now revised as:

• Targeted genomic sequence analysis panel, solid organ neoplasm, 5-50 genes (eg, ALK, BRAF, CDKN2A, EGFR, ERBB2, KIT, KRAS, NRAS, MET, PDGFRA, PDGFRB, PGR, PIK3CA, PTEN, RET), interrogation for sequence variants and copy number variants or rearrangements, if performed; DNA analysis or combined DNA and RNA analysis.

Basically, this is pretty trivial wordsmithing, from an early statement "DNA analysis and RNA analysis if performed" to a closing statement "DNA analysis or combined DNA and RNA analysis."   While AMA may have seen a syntactic preference here, it's hard to see it is a difference that makes a difference.

What's new are the new RNA specific codes, one for each of the existing base codes 81445, 81450, 81455.

Here are the changes as I read them:

81445 Solid cancer 5-50 genes

    No change except rephrasing the options of (DNA) only or joint (DNA & RNA) analysis

    New code option 814X1 for RNA analysis only

81450  Heme cancer 5-50 genes

    New code option 814X2 for RNA analysis only

81455  Solid cancer or heme cancer, 51 or greater genes

    New code option 814X3 for RNA analysis only

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Given the "14 day rule" at Medicare, it seems that if you do DNA-RNA analysis on Day 1, you get a code that is the same (or a trivial adjustment) to the existing codes 81445, 81450, 81455.   However, if you do an RNA analysis alone AFTER day 14, then it would be code-able as one of the new RNA only codes (X1, X2, or X3).

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PGX / Pharmacogenomics Coding

Also of interest in genomics, there's one other genomic sequencing procedure new code, which is 8X000, drug metabolism (pharmacogenetics), at least 6 genes, including CYP2C19, 2D6, and 2D6 dup/del analysis.

Code 0X47U, psychiatry, 15 genes, is not listed with a brand name on the CMS worksheet, but matches Myriad Genesight, based on the public PLA code agenda for April 2014 released by AMA in mid-April.  Both codes 8X000 and 0X47U will be up for pricing decisions at the summer lab meeting.