Wednesday, December 13, 2017

MOLDX: Apparently Cancels Instructions for Modifier 22 Billing for PMA CDx Genetic Tests

For several years, MolDx had special instructions if you billed oncogenes like KRAS or EGFR with FDA approved tests:  Add modifier 22.    While MolDx never published fee schedules for added payments triggered by modifier 22, CMS open payment records by lab for 2015 show that some labs, like Genoptix, were paid about 2X the fee schedule rates for some tests (here).

Policies have changed.   The old MolDx covered test instruction page was "Approved Gene Testing, M00041, V16," and it's gone.  (For a November 2 archive of how it was, here.)

The new equivalent article is, "Approved Molecular Tests for Reimbursement, M00149, V1."  It lists "routine" genetic CPT codes that are considered payable, and it also lists those genes inside of Tier 2 codes that are considered payable.  Special instructions about -22 coding are now gone.

Concurrently, MolDx has published coding articles for FDA EGFR, KRAS, and BRAF tests (here, and screenshot below.)  The articles lack the prior Modifier -22 instruction.

click to enlarge

MolDx Likely to Use Flat Tier 2 Prices in 2018 Under PAMA 

It looks like MolDX has also deleted its quirky schedule of very specific and elastic gene by gene prices for Tier 2 codes (cloud archive here) and presumably will price Tier 2 at flat PAMA prices in 2018.

Multi Gene Discount Article Still In Effect

Still active is the MolDx "panel alert" article that if you bill more than two gene CPT codes they should be replaced by 81479 and a Z code, presumably for discount pricing.