Thursday, November 9, 2023

Trade Journal Watch: 360DX Covers CMS Underpricing of New Cancer GSP Codes

 On October 30, I wrote a blog that AMA CPT had added a long series of new comprehensive genomic profiling (CGP) codes for 2024,and that CMS had proposed to price them all at about $600.

The topic is highlighted in a deep dive article by Kelsy Ketchum at 360Dx, one of the Genomeweb-family trade journals.   Find it here (Subscription):

As the new article explains, AMA stakeholders produced a number of codes for LBX tests and for CGP tests that explicitly includes features like MSI and TMB, tests with CMS fee schedule prices around $3000.   CMS proposed to price all the new codes right about $600.   

In the subscription article, several prominent authorities state the proposed CMS pricing makes no sense and is clearly underwater for labs.

My two cents, CMS will have proposed $595, CMS will have gotten numerous vigorous protests, and will likely respond ot the noise the way a ground hog would on groundhog day - CMS will duck in its burrow and send the disputed codes to Gapfill in 2024.

Argument is, services like MSI, TMB, require more than 50 genes, although not named in the codes.  CMS was skeptical, and prefers to price based on explicit words of a code only.   AMA CPT might have put the remark "more than 51 genes," in the definitions of MSI, TMB, in the book.


SALSA, the legislative PAMA reform act, would cap price changes at 5% up or down.   If CMS misprices a test (or if scant data leads to super high or super low PAMA pricing), the fixed priced could only migrate by 5% a year.   For example, if SALSA rules were enacted, if CMS priced these tests at $595 and PAMA prices came in at $4500, the tests would only move up by $15 or so ($610) per year.  (It would take about 35 years at 5% per year to reach from $595 to $3300).