Thursday, December 16, 2021

CMS Officially Recognizes: PAMA Delayed by Another Year

Update: Release of 2022 fee schedule circa December 30 - here.


Under the original PAMA Schedule, prices for tests paid in 1H2019 were to be reported in 1H2020 for the 2021 fee schedule.  It was delayed by two years.

Newly, on December 10, the Protecting Medicare act  added another year's delay.  Now, prices for tests paid in 1H2019 will be reported in 1H2023 for pricing in 1H2024.   Presumably, that will be a three year fee schedule for 24, 25, 26, so that prices in 1H2025 will be reported in 1H2026 for a new three year schedule commencing 2027.

Which Means...

Another way of saying that, median prices observed 1H2019 will be applied until December 31, 2026.

There will be no payment reductions as we leave 2021 and enter 2022.  CMS has delayed issuing the CY2022 CLFS fee schedule, which will soon appear here.  On that webpage, wait for the appearance of a file titled, "22CLFSQ1."

PLA Codes in PAMA Limbo

The highest PLA code in the six months of 1H2019 was 0061U (a 5-biomarker tissue oxygenation code which had 378 payments in CY2020 at $25 each).  AMA is already up to 305U (RBC morphology biochip).  That means all the codes from 0062U forward will have missed the last PAMA data capture cycle in 1H2019 and won't be surveyed until the next PAMA data capture cycle way out in 1H2025.  As I read the regulation for pricing (though it's a bit mind-bending), tests sit at their new crosswalk/gapfill prices until the next PAMA cycle they are eligible for.  

(Alternatively, if codes higher than 0062U are considered "codes with no applicable PAMA information" when they reach the PAMA pricing process of summer 2026, hundreds of such PLA codes would enter the crosswalk/gapfill process all at once.)  


CMS writes,

Medicare Clinical Laboratory Fee Schedule Private Payor Data Reporting – Delayed until 2023

On December 10, the Protecting Medicare and American Farmers from Sequester Cuts Act delayed the Clinical Laboratory Fee Schedule private payor reporting requirement:

  • Next data reporting period is January 1 – March 31, 2023
  • Reporting is based on the original data collection period, January 1 – June 30, 2019

The Act also extended the statutory phase-in of payment reductions resulting from private payor rate implementation:

  • No payment reductions for Calendar Years (CYs) 2021 and 2022
  • Payment won’t be reduced by more than 15% for CYs 2023 through 2025

Visit the PAMA Regulations webpage for more information on what data you need to collect and how to report it.