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.
https://www.discoveriesinhealthpolicy.com/2023/10/and-then-there-were-12-proliferation-of.html
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.
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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).
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.
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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.
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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).
