Wednesday, December 4, 2019

CMS Posts Final New Lab Test Prices for CY2020

On December 4, 2020, CMS released pricing for some 90 new CPT codes for CY2020, as well as final decisions on several codes being reconsidered during CY2019 due to the appeals process on prices set for CY2019.

The CMS home page for Clin Lab Fee Schedule (CLFS) files is here.

The ZIP file for the new prices is here.

My copy of the summary file is in the cloud directly, here.

CMS released the files in several ways.  Two files are comma-delineated files, one summary and one complete.   CMS also released a two-worksheet Excel file with all the data in two tabs.

Closing Out the Results of Gapfill CY2019

CMS also released final MAC prices for codes under the gapfill process during 2019.  See earlier blog on these codes here.   Generally, there were no changes between proposed and final MAC gapfill prices.  See final CMS file for 17 codes in cloud here.

Update January 2020:
I got a FOIA 57 pp PDF of public comments on the GAPFILL prices.  I put it in the cloud here; four companies made comments.

New Codes for 2020: Highest Gapfill Cohort Ever*

About 37 of the 87 codes (the 87 excludes codes removed from the process) enter the gapfill process for CY2020.  This is more than double the codes gapfilled currently in CY2019.

In the gapfill process, the multiple MACs set proposed prices in the spring, there is a public comment process in the summer, and CMS sets final prices in the fall (in this case, December 4).

Changes from Proposed to Final

12 codes were converted from crosswalk to gapfill during the fall public comment process.
1 code was changed from gapfill to a crosswalk.
3 codes were crosswalked again, but to a different crosswalk.
2 codes were removed from pricing because they are now ADLT codes.
1 code was deleted.

CMS Prefers Single Simple Crosswalks

Of the approximately 50 codes crosswalked, the vast majority had a single simple crosswalk.  6 codes were crosswalked to the sum of 2 codes, and 1 was crosswalked to the sum of 3 codes.   2 codes received  fractional crosswalks (one x 0.5, one x 1.5).   PLA codes were used as the crosswalk target 7 times.

PLA Codes

Since the majority of codes are PLA codes (72 PLA codes in the final pricelist), they are worth assessing separately.  Of 72 PLA codes, 36 or 50% were gapfilled.

Of crosswalked PLA codes, 22 were crosswalked to only one regular CPT code. 7 were crosswalked to another PLA code.  7 were crossed to a multiple or stack of regular CPT codes.

Appeal Codes: BRCA Unchanged

Most of the appeal codes, including BRCA price appeals, were not successful and CMS will retain CY2019 pricing in CY2020.

Reconsiderations for 2020

Parties dissatisfied with the pricing results just released by CMS may submit reconsideration requests for 60 days (30 days for gapfilled codes; see CMS webpage at link above.) 

Regular reconsideration requests will cause the pricing for that code to be taken up de novo next summer.  CMS usually receives several such appeals each year.   It has no short term effect on pricing. 

Far less common, reconsideration of a code just gapfilled by MACs to a final price for January 2020 is different,  When this occurs, it is a reconsideration by CMS staff who assess whether the MAC gapfill price was irrational, and should be adjusted.  This process is handled internally and rapidly by CMS staff.


CMS issued special additional comments wherever it disagreed with both the advisory panel and public comment.   In general, CMS explanations of rationales for price selections are better this year than in past years.

An early version of this blog undercounted the gapfills for 2020 as 20, not 37.