Monday, December 17, 2018

Very Brief Blog: CMS Releases CY2019 Full Lab Fee Schedule

On Friday, December 14, CMS releasd the full CLFS fee schedule for CY2019. 

There aren't surprises; CMS is implemented PAMA cuts released in November 2017 for CY2019, and CMS is releasing gapfill pricing or new code crosswalk decisions that had been posted in recent weeks.*

Find the fee schedule here.


New codes and pricing become effective January 1 related to BRCA testing, as shown in this table:


18 codes are under the gapfill process.



New code for inherited disorders panel, pan-ethnic, 81443, is the same price as Ashkenazi disorders panel, 81412 ($2448).

The CLFS has 2,015 lines, although some lines are duplicates with and without a QW CLIA waiver suffix (which doesn't change pricing, but allows the code to be paid outside a CLIA lab).   If you ordered every test once, it would cost $232,665.57.

The least expensive test is 81005, urinalysis, $2.41.  The most expensive is family member exome sequence (81416, $12,000) which logically should not be more than proband exome analysis (81415, $4780).   31 tests are over $2000.

As the result of gapfill pricing in recent months (over 20 stakeholders commented to CMS on this topic), whole genome sequencing is $5031 (81425), $2709 (81426 for family member), and $2337 (81427) for re-analysis.

After one of the longest journeys I have followed, and several years of changing prices at CMS, and a gapfill year, Sep9 landed at $192 (81327).  This represents the FDA-approved Epi proColon test.


* I haven't manually checked if any proposed final gapfill prices from October 2018 have altered.