Friday, September 30, 2016

CMS Posts Pricing Recommendations for CY2017 Lab Codes

On September 30, 2016, CMS posted the "crosswalk/gapfill" recommendations for NEW codes that will be used in January 2017 - as well as results of several appealed codes from last fall's pricing exercise.

The CMS homepage for the Clinical Lab Fee Schedule is here; the 8 page PDF for the new proposed prices for CY2017 is here.  You may want to view in tandem with the recommendations of the PAMA lab advisory panel, which CMS posted here.

The postings are "preliminary determinations" and comments are accepted and the final determinations may, in fact, change.  CMS states, "We  post preliminary determinations on our website in September...we accept additional public comments...through October of each year."

Note that this process is for brand-new 2017 codes.  Codes put in the gapfill process for this year (CY2016) had proposed MAC gapfill prices posted in the spring, but final MAC gapfill prices have not been posted yet (as of September 30, 2016).   That process is running late; CMS usually posts final gapfill prices by early September.  Details after the break.

A pricing summary below; see the full 8-page CMS PDF on the CY2017 prices here.

Drug Testing Codes

Codes for definitive drug testing are being used by CMS, G0480-G0483.  There was a reconsideration request due to underpricing.  Current prices are $79, $123, $166, $215; there was a proposal to raise to $147, $196, $246, $295.  CMS is countering with a proposal at $116, $159, $202, $252.  CMS also proposes creating yet another new G code (see the PDF for details).

For presumptive drug testing, CMS proposes to crosswalk its current G code pricing (G0477, direct optial; G0478 instrument assisted; G0479 instrumented) to newly issued matching AMA CPT codes newly created by AMA:  80305, 80306, 80307.

Other Codes

Sept9, 81237 had most recommendations for 81288, but CMS has chosen 81287.  Stakeholders will probably point out to CMS that the great majority of commenters be the guide for CMS pricing.
CMS admits that "only one commenter recommended 81287."  To my knowledge, even that was a temporary error by AMP and was correctly publicly by AMP, both on video of the meeting and in a separate AMP letter to CMS (here).  Panelists voted 9 for 81288, with three for gapfill.  No one voted for 81287.

81413, cardiac channelopathies, crosswalk to 81435 (Lynch syndrome).  The add-on code for dup/del analysis crosswalked to the analogous code for Lynch.

81422, DiGeorge microdeletion, crosswalk to 81435 (Lynch syndrome).

81439, inherited cardiomyopathies, crosswalk to 81435 (Lynch syndrome).

81539, 4KScore.  Crosswalk to 3 times 81453 + 84154 (PSA total + 3x PSA free).

84410, bioavailable testosterone, crosswalk to 84402 + 84403 (testerone free + testosterone total).

87483, CNS infectious agent, 12-25 targets; crosswalk to 87633, respiratory viruses, 12-25 targets.

G0475, HIV ag/Ab, screening.  Crosswalk to 87389 (the corresponding CPT code without the "screening" designation.)

G0476, HPV, multiple types, in addition to PAP test; crosswalk to 87264, the corresponding CPT code without the screening designation.