Monday, February 8, 2021

White Paper on PLA Codes: Statistics, Trends, Impact on Genomics Coding

What does "PLA" stand for?  (Proprietary Laboratory Analyses codes.)  How are they impacting the coding for genomic tests?

When was the first PLA code created?   How many are there now?   How many are for human genomics, as opposed to drug tox testing or microbiology?   How often are they crosswalked?  How often are they gapfilled?   What is the timeline for getting one?    

For answers, see a new white paper, "US Reimbursement of Genome Wide Sequencing: A Coding and Pricing Perspective."

  • Find the white paper here.

It's PLA-ology!

For example, of 212 PLA codes created as of July 2020, 165 were for human tests, and 47 were for non-human tests (either drugs or pathogens).  Of the 165 human tests, 46 were MAAA tests and 119 were non-MAA A tests.  13 PLA codes were exomic or genomic (including whole transcriptome and joint germline/tumor analyses).  

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Turning from test type to pricing method, of 123 codes in the CMS pricing process by last summer, 63 had been crosswalked, and 24 gapfilled, with 36 more in the active gapfill process.  Only a few PLA codes were priced at CMS by the "ADLT" process (Advanced Diagnostic Laboratory Test pricing rules.)
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The white paper compares existing CPT Category I genomic codes with the growing library of PLA codes.  The paper closes with a "case study" of a real-life lab getting a PLA code and seeing it through the pricing process, and a discussion of some issues and predictions for the future.


Editorial content and data analysis and any errors are the sole responsibility of Bruce Quinn Associates LLC.  We thank Illumina for support of the research work for this study.


One thing I didn't mention in the white paper.  Every PLA code gets a short clinical and technical description in each year's edition of AMA CPT CHANGES.  You can buy these as paper books or eBooks (see AMA CPT website or Amazon), and you buy buy them as part of a (fairly expensive) subscription to Optum Encoder Pro plus an add-on Total-CPT services package.