Monday, January 22, 2024

Understanding the CMS Lab Price Gapfill Process for 2024

Header: Each January I like to remind us that the Gapfill lab test pricing process is underway, because CMS and the MACs do so haphazardly.


Here's my article from a year ago, January 2023.

Each summer for the last several years, CMS has had about 100 new lab codes to price.  It prices about 70 of them by crosswalking to the price of an existing test.   The other 20-30 are "gapfilled" under which three groups of MACs (the MolDx group; the NGS MAC group; and the Novitas-FirstCoast group) submit proposed prices for each code to CMS around March-April 2024.

How do those MACs decide on those proposed prices?  

In past years, sometime circa late January, the Novitas, First Coast, and NGS MAC contractors post a web article about how interested parties can submit info for pricing, usually against a deadline of mid to late February.   

The MolDx MACs generally make no web posting, and say that, when asked, they know how to reach each gapfill lab if needed.   However, sometimes it's not clear how MolDx pulls that off (by emailing ""?)   If you have a code under gapfill and if you haven't heard outreach from MolDx by Feb 1, I usually recommend you email them.

Novitas, FCSO, NGS MACs Usually Publish Web Info

In recent past years, MolDx has used an excel spreadsheet template for inbound information and Novitas/FCSO have used a web portal questionaire.  This is a year old, but it's last year's info page at NGS MAC (here).


By using the 2024 lab fee schedule and using codes finalized by last summer and with a $0 price for 2024, I tally 21 new PLA codes in "gapfill" now.  (Counting 80,000-series codes, I tallied 30 for gapfill in November; the table below is the PLA codes).

How 2024 Plays Out

MACs get their proposed pricing to CMS by April 2024, and CMS publishes those prices for comment.  in the fall, CMS publishes final gapfill prices, having shared those public comments with its MACs over the summer.

CMS sets prices as the median of the MAC proposal, but for quirky reason does this basically by state.  Since MOLDX has 29 states, it controls that median value and only the MolDx value sets the next year's national median.