Here information on Final Gapfill Prices for CY2023, and an update on the wait for Final New Code Prices for CY2023.
CMS released 2022 gapfill process lab prices in May 2022, and released final gapfill pricing around October 5, 2022. Sorry I missed the event at the time.
- While there isn't an explicit form or process for "final gapfill appeals," the deadline to register a complaint with CMS staff on the final gapfill prices is November 4, 2022.
- A few times, in ten years, I have seen those last minute complaints result in a price change.
- The vague regulation about gapfill appeals has the catchy name, 42 CFR 414.509(b)(2)(iv).
See the file on the CMS Lab Fee Schedule public meeting (and files) website.
Scroll down for the heading GAPFILL and see FINAL 2022 GAPFILL PRICES (zip file). (These are called Final 2022 Gapfill Prices, because it is a 2022 MAC process, but the prices are for the fee schedule of CY2023).
Four Codes Wanted Higher Gapfill Prices
Four of 35 gapfilled codes were appealed with additional pricing info. Responses are from MolDx, which controls the median of the national gapfilling process. Codes 81560 and 0018M (related to transplants) were lifted from only $263 up to $640. MolDx writes, "there was a pricing factor not previously considered under the Equitable Pricing Model." The EPM is the process and internal rules that help MolDx navigate from input data to a final price. Details of EPM are a business secret of Palmetto MolDx (I have a FOIA record with this response).
Two other codes 0245U (a thyroid molecular test) and 0248U (a cell culture cancer test) were raised less dramatically. 0245U is $1266 up from $1195. 0248U is $3033, up from $2698. Of note, the company with 0248U had two newer PLA codes in the summer 2022 crosswalk process, and CMS proposed to crosswalk them to around $1000 in September. In an October 2022 AMA posting the same two codes were posted for deletion from PLA.
We can draw three conclusions from the final Gapfill table:
- MACs don't play "gotcha." No prices mysteriously changed or dropped, absent requests or appeals.
- Few companies submit additional information in the summer, at least from the final spreadsheet, it appears only 4/35 had comments.
- At least this year all codes requesting up-pricing got some, ranging from a few percent to more than 2X.
New Code Prices 2023
In mid September (a bit late) CMS released some 100 new code proposed price for CY2023. CMS took public comment til mid October, and CMS will release final prices in mid to late November.
At that point, a stakeholder can file an appeal, but the result is that the code continues at the 2023 price, and brought back into the next summer's pricing meeting again for a possible new price in 2024.
Final Gapfill Prices ("Final 2022 for CY2023"). Click to enlarge.