Thursday, December 10, 2015

AMA CPT: 1Q2016 Will Be Very Active!

The AMA CPT editorial process has become much more public and open over the last several years.  One key improvement is that the AMA CPT meeting agendas are now posted publicly well in advance on the AMA website.

New hot topics will include (1) quarterly special AMA CPT lab codes; (2) AMA CPT responses to CMS changes regarding drugs of abuse lab test panels; (3) several new MAAA codes, including one for "comprehensive pharmacogenetic data," and (4) potential changes to the 88361 IHC code.  And (5) AMA initiatives for telemedicine coding are also reviewed below.

The main CPT (and RUC) page is available here.  Note that some hotlinked PDF documents may require free registration before downloading.  A month or so after each CPT meeting (February, May, October) AMA also posts a summary of panel actions, informing the public whether it accepted or deferred a coded application (here).

The February 2016 AMA CPT meeting in Miami will be an active one for lab tests.  Agenda posted here and discussed below.


PAMA, a 2014 Medicare law, requires CMS to completely revamp the lab test payment process and some aspects of lab testing coding.   Based on actions at the October 2015 AMA CPT meeting, and later decisions, AMA CPT has announced it will establish a new section of clinical laboratory test codes that can be issued as rapidly as quarterly.   This fulfills a requirement Congress imposed on CMS where quarterly codes were not otherwise available.  AMA CPT will hold a teleconference on December 15, 2015 at 2 pm CST (see website, as was current on 12/10/2015).   AMA writes,

In early November, the Panel authorized the establishment of a new section in the CPT code set. The new section established by the Panel provides an infrastructure whereby a clinical laboratory or manufacturer that meets certain criteria may request a code to more specifically identify their test. This section is separate from the Category I Pathology and Laboratory section and will include ADLTs and CDLTs as defined under PAMA. The clinical laboratory or manufacturer that offers the test must request the code.
It is envisioned that the codes in this new section will be issued on a quarterly basis and effective the following quarter to allow payers time to load them into their systems. The Panel would be responsible for verification of the information submitted and codification of tests in this section. 


This publicly posted agenda is subject to change from time to time at the discretion of the AMA, but as of 12/10/2015 is available here.  Topics for panel voting on the 11-page agenda include the following:

Drugs of Abuse Test Coding:
  • Deletion of AMA CPT Drugs of Abuse testing codes 80300-80304.  Addition of 7 new codes (803X1 etc).  While these codes are not identified, they could represent the AMA CPT incarnation of 7 new CMS G codes for drug testing which CMS will implement unilaterally on 1/1/2016.   AMA CPT also listed a long section of additional DOA codes subject to review and guidelines revision.
Other Molecular & Oncology Test Coding:
  • A revision of code 80304 (which is currently "not otherwise specified presumptive testing") to a "definitive drug screen matrix assisted laser desorption ionization time of flight" (TOF) test.
  • Add on code for fetal DNA/maternal blood testing for DiGeorge syndrome
  • Addition of a Tier 2 RNA expression test for PRAME and LINCOO518 in melanoma.
  • Several MAAA tests:  for uveal melanoma metastatic risk, for cutaneous melanoma metastatic risk, for a four protein FSH and human epididymis proteins test; for a "comprehensive pharmacogenetic analysis."
  • Dul/Del analysis addition to the tumor panel somatic mutation codes (81445, 81450, 81455). 
    • 81445: Somatic tumor, 5-50 genes; 81450: leukemia/lymphoma, 50 genes; 81455: any cancer, 51+ genes. 
  • Revisions to 88360 (tumor immunohistochemistry with morphometric analysis) and 88380/88381 (microdissection codes) advanced histopathology codes.

Worth noting: 88360
Those using 88360 should read the AMA CPT revision description carefully ("Request to revise code 88360 by clarifying that tumor immunohistochemistry refers specifically to the 2 tests in parentheses, and that the tests are not 2 of several examples of the test.")   The current code is "morphometric analysis, tumor immunohistochemistry, e.g. Her-2/neu, ER/PR.")

Worth noting: 81445 et al.
The addition of Dup/Del analysis to 81445, 81450, 81455 is interesting from a pricing and policy standpoint.  A "new or substantially revised code" enters the annual summer CMS crosswalk/gapfill festival of meetings.  CMS would determine whether Dup/Del analysis is a "substantially" revised code.  Currently, CMS has assigned pricing of about $600 to 81445 and 81450, and no price to 81455.  Many in the industry felt this was an infeasably low price.  If PAMA proceeds on schedule (which may be unlikely) the CMS pricing would be reset to "market prices" on 1/1/2017, which may be higher than $600.  (For example, labs might submit charges of $3000 and be paid 40% of charges of $1200 - just a guess.)  On the other hand, if the codes are considered "substantially revised" they would enter a crosswalk process or a gapfill process anew, in 2017 or 2018.

Worth Noting: The Pharmacogenetics MAAA Code

Despite notoriously conservative payer policies about pharmacogenetic (e.g. CYP) testing, two of the three highest paid genetic CPT codes in CY2014 CMS data were CYP2D6 and CYP2C19, totally about $250M in payments (here).  (For a Genomeweb article on the field in November 2015, see here, also here; for a JAMA Internal Medicine article on "clinical utility data for pharmacogenetics," see here.)  Specifically under the "MAAA" section a "comprehensive pharmacogenetic analysis" code is proposed.  By definition, MAAA codes are test-specific.   Other companies in the space would presumably continue to stack individual CYP CPT or other pharmacogenetic codes.  Generally, MAAA tests provide single test results (such as the Oncotype DX score) which fits the PAMA definition of an Advanced Diagnostic Laboratory Test; the details and structure of a pharmacogenetic code might impact how well it foots to being an ADLT as well.


The AMA is also running a new CPT Telehealth Services Workgroup.  I include this under this "lab policy" posting because telehealth promises to someday provide a new way to deliver needed counseling for genetic testing as well as specialty consultation services related to tumor gene panels.  They will hold teleconferences and time to time in person meetings to ensure that AMA CPT stays at the forefront of the national telehealth agenda.  AMA writes (as current on 12/10/2015):

The workgroup seeks input from individuals who can provide the technical expertise regarding telehealth services to assure the ongoing relevance of the CPT code set. Participation in this workgroup is limited to parties with demonstrated expertise relevant to current telehealth technology and the clinical procedural aspects of telehealth services/procedures. Participants are expected to perform or represent those who perform the services under consideration by the workgroup and have the expertise and interest necessary to contribute to the workgroup. Participation is intended to provide expertise relating to general categories of telehealth and not to advance the proprietary interests of specific parties. As such, preference will be granted to professional and trade organizations that reflect a category of telehealth services rather than a single product. 
For more on AMA telehealth, see here.