Thursday, October 9, 2014

CMS Releases Prices for New CPT CLFS Codes - Gene Panels Get Gapfill

On October 9, 2014, CMS released its pricing decisions for all new CPT laboratory codes that will be active in 2015.

It finalized its proposed in on November 25, 2014.

The CY2015 Excel spreadsheet fee scheduled, released about January 1, 2015, is at the CMS website, here.  (See:

* Drug testing codes - use by Medicare is deferred, as is pricing by Medicare.
* Genomic tests - gapfilled.
* Exact Sciences ColoGuard - $502.

Codes were finalized by CMS as proposed.  Final CMS positions are posted here.  

Note that for specific drug tests, CMS produced some two dozen new G-codes to use, replicating 2014 CPT codes, instead of using new 2015 CPT codes. 

Details after the break.

Most notably:

Drug Test Codes Deferred.
CMS planned to defer use of dozens of new clinical chemistry drug testing codes.  It did so in the final announcement in November.  CMS stated its uncertainty about correct pricing of new CPT codes.  Text at bottom [*].

New Genomic Codes Gapfilled.  
CMS placed the new genomic codes for 2015 in the CY2015 gapfill process.  Medicare contractors will set preliminary prices in 1Q2015, and they will be released for public comment.  Medicare contractors will submit final prices in about August 2015, and CMS will publish the medians and set 2016 prices at those medians.

These molecular codes include the Oncotype DX breast cancer test (new CPT 81519).

Medicare treats what AMA CPT calls MAAA Administrative Codes equally and places them on its 2015 schedules as gapfill codes (0006M, 0007M, 0008M, the latter being the Nanostring ProSigna breast cancer prognostic test).

The 21 new codes for advanced genomic studies such as exome sequencing and whole genome sequencing, as well as a range of hereditary and cancer/somatic mutation genetic panels, will enter the gapfill process.

Exact Sciences Colon Cancer Screening Test - Cologuard - $502
The CPT code for the Exact Sciences screening test for colon cancer, recently FDA approved and already under a proposed favorable coverage NCD, was crosswalked to two genetic codes and an occult hemoglobin code (81315, 81275, 82274).  This is $282 + $197 + 21.   CMS concurred with the sponsor's recommendation.  Cologuard website, here.

The decisions were about five weeks late; they are normally posted around September 1.  Appeals can be filed in the next month, which CMS will consider next summer in its July 2015 pricing cycle.

See for yourself:
CLFS Homepage, here.
CLFS Fee Schedule 2015 PDF, here.
PDF at my cloud archive, here.


[*]    Drug Testing, CMS view:
Codes 80300 through 80377 (63 codes)
Industry Recommendation: Various, from crosswalking to specific existing codes (e.g.,
G0434, G0431, etc.), to gapfilling.
CMS Recommendation: Delay in pricing.
CMS ACTION: Replace 2014 CPT codes with "G" codes which CMS will use in 2015.  Don't use new CPT codes in 2015.
Rationale: These codes represent various drug screening codes, many of which are specific to individual drug testing. While we appreciate the recommendations for these tests, we are concerned about the potential for overpayment when billing for each individual drug test rather than a single code that pays the same regardless of the number of drugs that are being tested for.
Therefore, it is our recommendation to delay pricing for these codes at this time, until further information and education is obtained.