Tuesday, December 18, 2018

Very Brief Blog: Nerd's Update on AMA PLA Codes at CMS

PLA-ology As We Enter 2019

Section 216 of the Protecting Access to Medicare Act of 2013 revamped the Clinical Lab Fee Schedule, setting it triennially to market prices.  PAMA 2016 also required CMS to create rapid codes for new lab tests, which CMS could do through G-codes.  However, CMS generally hasn't had to troupe out new G codes to fulfill its responsibility, because new proprietary codes - PLA codes - are released released quarterly by the AMA.  See AMA PLA webpage here.  The next PLA deadline is Thursday, January 10, 2019.

The new 2019 CMS Clinical Lab Fee Schedule has 56 PLA codes on it. 

(By today, AMA has also created 22 even newer codes that haven't made it on the CLFS yet.)

Codes present on the CLFS were issued as recently as June 2018, and the codes that were under the recent summer crosswalk/gapfill process were issued between October 2017 and June 2018.

Of the 56 PLA codes on the CLFS, 18 are under the "gapfill" process for CY2019.   (This means they will be pricing by local MAC contractors in 1H2019). 

They gives us a library of 38 PLA codes that *have* been priced by CMS, some as recently as this fall.

All the PLA codes that active for 1H2019 will be part of the next PAMA pricing cycle.   This next cycle is expected to collect market prices in 1H2020 based on insurance payments to labs in 1H2019.

PLA-ology or PLAtistics

The priced codes range from $15, for 0039U, a high avidity DNA antibody measurement (BioRad), to 0036U, $4870, exome tumor and somatic analysis, from the Weill-Cornell genomics laboratory.    0036U was crosswalked into the PAMA price for exome sequencing (81415).   (Note that there is institution across the street in NYC, Memorial Sloan Kettering, which has an FDA-cleared tumor gene panel test, MSK IMPACT, 0048U, which is being gapfilled).

Near the top of the price chart is the Foundation Medicine F1 CDx test, 0037U, 324-gene tumor panel, which as a FDA-approved ADLT receives an annual market-based price for itself.  It is currently $3500.
  • 7 PLA codes price under $100.  
  • 8 price above $2000.   
  • That leaves 23 priced between $101 and $950.
Below, I give a chart of PLA codes that are priced by CMS, followed by a "click to enlarge" graphic of code names and prices.

click to enlarge
Anyone who's read this far seriously needs to get some new hobbies.  The data has a median of $247 and a mean of $918, with a (parametric) standard deviation of 1343.  Of course, the data is highly skewed and not a normal distribution (Excel skew value = 1.7) which means a parametric statistic like Std Dev is not meaningful.