Tuesday, October 3, 2023

CMS Releases Final Gapfill Prices for 2023

In late April 2023, CMS published proposed MAC Gapfill prices for about 40 tests for CY2023, triggering a comment period. On October 2, 2023, CMS released the final MAC prices.   Go to the CMS lab meetings page, and scroll down to "Meeting Notice and Important Documents" and "2023 final gapfill deterinations," a downloadable ZIP file.

Hard to See Commented Codes and Their Results

This year, it's harder than normal to detect the price changes.  

  • Normally, only a few codes have pricing complaints, and CMS provides a separate tab to explain how MACs handled those tests.   
  • (Last year, 4 out of 4 gapfill commenters asked for a higher gapfill price, and all got a lift, though sometimes small.)

This year, CMS seems to have republished nearly every code (about 30) on the final rationale page with no segregation of those for which pricing comments or complaints, were submitted.   

I manually compared all 31 codes from May with the codes now in October.   One test, Castle Squamous SCC, changed from a $3159 gapfill rec in May, to an $8500 ADLT price in October, thus, taken out of the gapfill process.

Of the remaining 30 codes gapfilled in October for 2024, there were 6 that had price changes.  All got price increases, by my manual calculations:

  1. 0299U, Praxis OGM test, up $600 or 47% to $1863.
  2. 0331U, August OGM test, up $600 or 47% to $1863.
  3. 0306U, Invitae Exome for MRD, up $794 or $26% to $3878.
  4. 0318U, Episign pediatric methyl genome, up $397 or 29% to $1770.
  5. 0326U, Guardant G360 (LDT), up $467 or 13% to $3967.
  6. 0329U, Exact Sci OncoMap, up $518 or $18% to $3438.

Again, unlike prior years, CMS doesn't segregate tests with submitted comments, so it's hard to know how many submitted comments with no change.  

But there's a clue that for test 0314U, NGS MAC says "will increase price to $1950."  This seems to mean that NGS MAC matched a final price that was already the May median, but I'm not certain.  

click to enlarge


The ADLT process continues to widely separate some tests.   For example, 0314U Castle, DecisionDx DiffDx Melanoma, is gapfilled to $1950 by MolDx, while 0315U (Castle Decision Dx Squamous/SCC) is ADLT priced at $8500.  And before the 0315U test was "ADLT'd" it had time to get a proposed MolDx price in between, from last May's gapfill, circa $3000.  

  • (In a recent blog about new crosswalk proposals for 2024, I noted that a category of tests - multiple slides plus AI or ML - were variably priced from $706 to $5435, being without or with ADLT rules, respecitvely).

Quest Alzheimer Test - Still Can't Make Triple Digits

The Quest code for plasma based amyloid and Alzheimer's, remains at $93 (line 41 of the main table, 0346U), some MACs suggested as low as $48.  (It recently had some negative press.)

PGX: $917

The AMA CPT code for 6 or more PGx genes, 81418, was sent to gapfill and has gotten a final price of $917.   Note that a few labs (e.g. Myriad) get a higher panel PGx price as they are paid via PLA codes that were priced earlier and separately from 81418.

Error 0332U 0333U

CMS publishes the same descriptor (the 332U descriptor) for both tests 332U and 333U.   333U is entirely different and the descriptor is wrong (should be Helio Liver).

As a rationale, NGS MAC says on every line, "Agree with majority of MACs," which in every case, means "agree with MolDx," which has the majority of the state zones that are tallied for the median.