Tuesday, August 9, 2022

CMS Publishes Voting Recommendations of Lab Advisory Panel for New Code Pricing

 We've gotten one more benchmark in the annual cycle of the new lab code pricing process.  CMS publishes voting records of the Clinical Diagnostic Laboratory Test panel.  They reviewed and voted on 105 agenda items in mid July.

Find the two day video archive as well as the PDF voting records here:


By my tally, the panel voted in substantial majority to gapfill 25 codes, and the panel split (at least 3-4 members going off tangent) on about 17 codes.   The rest of the codes (105-25-17 or 63) got crosswalk votes that were unanimous or nearly so.   About 5 codes got votes for a fraction-based price (e.g. 1.5X an existing code).   

Next step:  CMS releases its proposed prices in early September 2022, triggering a public comment period.

Biggest news of the meeting was that CMS reversed many years of prior (verbal) policy and allowed panelists to vote to crosswalk a new to the price of a test that is not yet priced yet, but is in the gapfill process.   I believe most presenters, in June, thought this was not possible because previously CMS has always said it was not possible.  It's also not possible to fulfill the agency's crosswalk information request, which includes listing the price of the crosswalked code.

There are pro's and con's to crosswalking a new code to an existing code that is unpriced and still, itself, being gapfilled.   In an index case at the meeting, a lab hoped its new code could be crosswalked to its own, and virtually identical code, that was being gapfilled at a price it liked.  So crosswalking the next code, to the in-process gapwalked sister code, saves everybody trouble. 

BUT, this could also go haywire.  

Worst case scenario!  Imagine a code that has no presenter or information at the summer meeting.  CMS puts it into gapfill, since CMS has no information.  The lab also provides no information to the MACs during the gapfill process, and as a result, is on its way to getting a desperately low price.  Would you want your new code to be crosswalked to that code, just because your code text was kind of similar?  And you have no real say in it?   No.