Friday, April 28, 2023

Brief Blog: CMS Posts Preliminary Gapfill Rates for CY2024

On the public home page for the summer laboratory test pricing meetings - here - CMS has posted Prelminary Gapfill Prices for 2024, in a cloud zip file, here.   MAC pricing suggestions diverged, in 7 cases, by over $1000


To find the link yourself, on the CLFS webpage, click on the Meeting Notice, Agenda, Important Materials link, and scroll for CLFS Gapfill Determinations, where you will find 2023: Preliminary Determinations (Zip).

There are about 32 codes in the gapfill process.  All except four, are PLA codes (ending in "U.")  


The spreadsheet has 2 tabs, one for prices (from every MAC) and one for rationales.   The page for rationales has 7 columns, which appear to represent MACs, but are not labeled.  However, some columns refer to MOLDX and one columns refers in each case to "allowanced developed by First Coast and Novitas" (column D).  Related to MolDx, many of these cells simply list "price based on equitable pricing model" which is an internal rule set developed by MolDx (EPM).

Gapfill Statistics

There can be pretty wide divergence.  For example, 81418, a new CPT code for PGx panels, is priced at $917 by MolDx but $168 by Novitas.  (In many other cases, Novitas exceeded MolDx).

While the median gapfill prices always match the MolDx MACs, divergences among the three MAC systems (MolDx, Novitas/FCSO, and NGS MAC) were the rule.  

I found divergences - ranging from $11 to $7186 - in 31 of 32 codes.

Seven Divergences > $1000

7 of the codes had divergences (defined as max minus min) over $1000, ranging from $1400 to $7186.

NGS MAC often, but not always, matched MolDx.

Two of the highest divergences were:

0297U, Oncology, pan tumor, WGS (tumor, germline), MolDx $2919, and Novitas $7741. Delta, $4822.

0300U, also Oncology, pan tumor, WGS, MolDx $4183, Novitas $9713.  Delta, $7186.

click to enlarge but see also Cloud Google file

See My Cloud Spreadsheet with MAX, MIN Data


A Few Other Notes

0285U, cfDNA, response to radiation, ranged from $30 Novitas to $443 MolDx/NGS-MAC (Ratio over 10X).

0338U, rare disease WGS, ranged from $251 Novitas to $2435 MolDx (slightly different at NGS-MAC) (Ratio about 10X).

346U, Abeta ratio, amyloid, Alzheimer, ranged from $48 Novitas up to $93 MolDx and NGS-MAC.

Do Gapfill Prics Change, Draft to Final?

Last year, there were 35 codes in gapfill, and only 4 received summertime gapfill comments, per CMS's final spreadsheet.  All had upward changes (e.g. $263 to $640 and $1195 to $1266 and $2698 to $3033.