CMS Releases CLFS Fee Schedule for CY2025

CMS has issued the Clinical Laboratory Fee Scheduel for CY2025 (First Quarter).

This consolidates all existing codes, all new codes for January 2025, and the results of all the appeals and gapfill processes that were running last summer.   It gives final pricing for the rather massive list of tumor genomic sequencing procedures created by AMA over the last several years.

Find the table for 2025 here:

https://www.cms.gov/medicare/payment/fee-schedules/clinical-laboratory-fee-schedule-clfs/files

See also the PDF update for 2025, CR13889,  Transmittal 12992, dated December 13, 2024.

https://www.cms.gov/files/document/r12992cp.pdf

This latter PDF gives all the crosswalks assigned newly for 2025.  If you had the equivalent table for 2019, 2020, 2021, 2022, 2023, you could recreate all the codes on the fee schedule that are based on underlying crosswalk calculatiosn rather than direct prices.

The CLFS has about 2,080 codes.  About 35 have a "zero" price meaning they are in the 2025 gapfill process.

Six Codes over $7000

Six tests have fee schedule prices higher than $7000.   These are 

•  81529, cutaneous melanoma, $7193
• 0094U,  rapid whole genome $7582
• 0211U, oncology, pan tumor (Caris) $8455
• 0315U, cutaneous squamous carcinoma, $8500
• 84116, exome, comparator, $12000

The last code, 84116, I believe to be an anomaly from PAMA pricing in 2017.  An exome is about $4000, and  some infants may require a "comparator genome" of each parent.   84116 was probably miscoded by someone as an exome triplet (baby, mother, father) for $12000.  But read correclty, the code would be for 1 parent exome ("each"), which shouldn't cost more than 1 baby exome.  Also called a "rank order anomaly" in the fee schedule world.