Thursday, January 2, 2020

CMS Updates PAMA Page for New Law: Reporting Year Is Delayed, But Year 4 at 15% Cut Is Not

CMS has updated its PAMA REGULATIONS page to account for new law passed in late December, section 105(a)(2) of the Further Consolidated Appropriations Act of 2020 (FCAA).  See PL 116-94 (HR 1865) online here, here.  It's Division N, Title 1, Subtitle A, Section 105.  The statutory language is clipped here.  It's cryptic since it inserts and deletes bits and pieces of phrasing into existing law not directly shown in PL116-94 (see SSA 1834A, here.)

FCAA does the following:
  • Leave the payment data period for the next three-year PAMA cycle the same, 1H2019.
    • Claims paid during 1H2019 for active codes in 1H2019 will be part of the next PAMA data collection.
  • Delay the data collection from 1Q2020 to 1Q2021.
  • Delay the implementation of new prices to January 2022.
CMS notes that another time cycle is not changed, in its view.  This time cycle provided 10% pay cuts (at the max) in Year 1,2,3 under PAMA, and 15% pay cuts (at the max) in Year 4,5,6.   Since 2020 is Year 3, pay cuts are limited to 10%, but since 2021 is still year 4, pay cuts will be 15%.

Whether lab tests get a 15% cut in CY2021 depends on whether the 2020 price is still 15% higher than the price median found based on 2017 data.

CMS updated the top part of its PAMA page, here.  See table (click to enlarge) clipped below.

click to enlarge
By my informal tally, comparing 2020 current prices to the median of 2017 reported private payer prices, about 206 CLFS CPT codes will have a 15% cut in CY2021 if CMS's update is correct.   Another group of about 390 will have a 10-15% cut and finally about 130 will have a 0-9% cut.

I've put my personal best-effort spreadsheet in the cloud here.  This Excel has two tabs; one sorted by percent cut 2021 (my prediction), and one sorted by CPT.

Recall there were some huge anomalies in PAMA reporting pricing; for example, 81341 TRB gene rearrangement had a CPT price of $68 in 2017 but a PAMA median price target of one penny.   81435 Lynch Panel had a CMS 2017 price of $802, but a PAMA median price target of $37.99.