Tuesday, September 22, 2020

CMS Releases Proposed Prices for Clin Lab Fee Schedule CY2021 - Public Comment Open

CMS has posted Preliminary Payment Determinations for the CY2021 Clinical Lab Fee Schedule on its website.  I've also placed a cloud copy here.   

Notation in the Excel spreadsheet informs us that comments are accepted until October 21, 2020 at: 


There are 132 agenda items, the most ever.


By my count (and using the Excel filter/display function) about 53 of 132 codes are gapfilled.


Based on past years, a significant proportion (a third?) of these values can change between the proposed and final pricing determinations.


CMS covers the first COVID testing codes from last spring at about $50 (carrier rates, standard COVID) or $100 (CMS administrator's rate, high throughput COVID) - U0001-U0004.   CMS recommended all of these codes be "gapfilled" during 2020.

CMS also recommended additional COVID codes be gapfilled: 87635, 86328, 86769, 


For observers of Myriad's Genesight test and pricing (currently locally priced at $1569 by MolDx; see recent news reports quoted here) - CMS sends the 14 gene psych PGx panel 0173U and the 15 gene psych PGx panel 0175U both to gapfill.    0173U and 0175U belong to RPRD Dx and Genomind, respectively.  If these codes enter the Gapfill process, which is dominated by the 28 MolDx states controlling the gapfill median, the simplest prediction is that MolDx prices these PGx tests at the parity rate to Myriad Genesight and AltheaDx test both at $1569 and due to the 28 MolDx prices, the 2021 gapfill median will be $1569.*


Six codes were under the reconsideration process, meaning stakeholders were unhappy with their pricing by crosswalk last fall.  4 of the 6 are to be gapfilled in CY2021.  In these cases, panel experts had unanimously or almost unanimously recommended gapfill.  In the other two cases, a large majority of panelists had recommended the same crosswalk.


In a new trend, two multi-pathogen tests were approved by AMA as MAAA CPT codes (81XX4, 815X3).  They were crosswalked to 87631 (resp virus 3-5 $143) and 87506 (GI virus 6-11, $263), respectively.    The text for the tests tests doesn't sound so dissimilar - 

Genome-web cytogenomics

Three codes for genome-wide cytogenomics were gapfilled.  0209U: No public comment; panel recommended gapfill.   0156U: Applicant asked for current microarray cytogenomics code 81229 x 1.5 (about $1500).   021U: (chromosomal analysis + exome sequence): applicant asked for very elaborate crosswalk stack (I believe about $12,000); gapfill.  


That's a long sentence but shows my three years of studying German grammar in college weren't wasted (long sentences).