Monday, November 28, 2022

CMS Finalizes New Code Pricing for CY2023

On November 28, 2022, after market close, CMS posted final prices for new lab test codes for CY2023.

Find the zip file at this page, and search for CY2023 Final Payment Determinations.

I've also posted a copy, a Google Sheets cloud version, here.

Brief Analysis

There are 104 agenda items.  The final decision on 34 codes is "gapfill."   A change analysis suggests that CMS made changes in 15 codes, of which 12 were a shift from a crosswalk to gapfill.  No codes shifted the other way, from gapfill to crosswalk.  Just 3 codes were a shift within the crosswalk to a different crosswalk.

Those 3 shifts in crosswalk were a related triplet of codes (0308U, 0309U, 0310U) were all shifted from crosswalk of 81506 to 0163U.  The codes are Prevencio codes for 3- or 4-protein cardiology MAAA tests, and 0163U prices them at $390 (the Beacon BeScreened CRC test).  

Only 6 of the crosswalked codes were crosswalked to a pair of codes or rarely, a multiple of a code.  The rest of the crosswalks were simple crosswalks to a single code.  

By my tally, of the crosswalk targets, 44 were regular CPT codes and 26 were PLA codes.  Of the PLA codes, 0203U was used as a crosswalk target 4 times, and 0175U and 0163U each 3 times.

Quest Alzheimer Amyloid Test

CMS had proposed to price the Quest LDT serum amyloid Alzheimer test 0346U to a very low price (around $20) but this is one of the 12 codes that switched from crosswalk to gapfill in the review process.  I'm sure this was a big relief for Quest.   In next year's pipeline, we'll probably see coding and pricing for the FDA-approved Fujirebio amyloid test, which is a CSF based test.

PGX Codes

I noted in a blog that there were a range of PGX panels under pricing review, and that the prices seemed to jump around in a willy-nilly fashion I could not understand.   There were no changes to these final PGx prices, except the general CPT code panel 81418 was switch from a $742 crosswalk to the gapfill method.

ADLT Policy?

In agenda FACA #34, ALM #62, 0326U, in the "rationale" CMS says it will gapfill the code in question rather than crosswalk it.  However, they also seem to newly raise a question as to their positioning on using ADLT codes as the target for a crosswalk price.   CMS did not mention this in prior publications or in the annual public meeting, so they seem to be raising a new policy issue in an obscure way (buried inside of 1 of 100 comments today.)


You can file an appeal until January.   Appeals merely result in the code being taken up again, as if new, at the Summer 2023 pricing meetings for CY2024.   Appeals do not change the 2023 price published today.

CMS writes:  We welcome reconsideration requests on our final determinations for the basis of payment.  All comments must be submitted electronically by January 28, 2023 to the following CMS mailbox:  When submitting reconsideration requests, please refer to the specific code and its rationale.

Nerd Note on Price Stability re PAMA Years

Codes that are crosswalked in this posting will change to new PAMA prices in CY2024, if the crosswalked target code was in use in 1H2019, the reference period for PAMA CY2024-2026.   

I believe if a new 2023 code is crosswalked to a code released after 1H2019, a code which has no data for 1H2019 PAMA collection, then, the price of the crosswalk target and of the new 2023 code remains the same until the crosswalk code is mature enough to go into the next PAMA cycle (data 1H2025, collection 2026, pricing 2027).  But by that time, the new 2023 code will also be active in 1H2025,  so it will get its own PAMA price and be detached from the crosswalk target code.  (Whew!)