Sunday, December 10, 2017

CMS Code Edits for CY2018 Block Use of BRCA Code 81211 At Same Time as BRCA Code 81213

See my earlier October 2017 article here

Each quarter, CMS updates its "Correct Coding Initiative" edits, typically with a larger update for each new calendar year.

CMS has released its Procedure to Procedure Edits for lab codes for CY2018, available at the CMS CCI website, here.

  • CMS has changed the edits to block joint use of BRCA Sequencing (81211) and the add-on or stacked code 81213 (BRCA dup del analysis).   CMS has altered the rationale to "HCPCS/CPT procedure code definition."   
  • I believe the underlying rationale has to be that if you do BOTH, BRCA sequencing and BRCA full dup-del analysis, they are replaced by the comprehensive AMA CPT code 81162, which is for full BRCA sequencing with full Dup Del analysis as one code.   

This has important fiscal implications for CMS, because under PAMA, the price for the code stack (81211+81213) rises (to about $2900 total) but the price for 81162 as a comprehensive code falls steadily.

81162 will pay $2253 in 2018, and $2018 in 2019, and $1825 in 2020.

Fiscal Impact for CMS

For example, at 20,000 BRCA cases per year, for CY2020 CMS would have paid $58M at the code stack rate; but only $36M at the comprehensive code rate, an instant savings of $21M.  Private insurers may follow CMS edits like this, but are not required to.

Screen shot from the 2018 CMS edit instruction:

click to enlarge
Manual for 2018 Available

The CMS CCI staff also released a manual of instructions (in PDF text form) in December, available online here.  See the link at bottom of the CMS webpage for NCCI Policy Manual (zip file of PDF chanters).

The "1" modifier in the table means that the edit can, or could, be overridden, but CMS manual instructions state only to allow that in uncommon circumstances where a special circumstance is justified by review of the medical record.

Note that CPT code 81432 (BRCA panel sequencing) is NOT blocked against 81433 (BRCA panel Dup Del) because there is no single code that represents the services 81432+81433.