Header - CMS has released gapfill proposed prices for about 34 codes. These are codes that failed to be priced in Fall 2024 by crosswalk, so they are transferred to the MACs for pricing during 2025. Comment will be open for 60 days (June 28).
The Monday April 28 version had typos; the Tuesday April 29 version corrects them, according to a CMS email.
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Find it here:
On this webpage, scroll down to "Meeting Notice, Agenda, Other Materials" and then scroll down to "CLFS Gapfill Determinations" and then find "CY2025 preliminary Determinations."
Typos
These have been corrected as of 04/29, per CMS email.
A Couple Views
Some of the prices were not too surprising.
- For example, 0485U, the CARIS ASSURE test which includes CHIP testing of WBCs, has a MolDx price of $3649, the range for complex LBX comprehensive tests.
- However, it might also suggest there's not too much financial bonus for adding workflow for CHIP testing, something that may be increasingly important (Caris/Magee 2025).
- Prices are subject to revision in September after the comment period.
- 0426U, an ultra-rapid genome for pediatric cases, comes in at $7582, the value CMS has used before for a regular rapid genome (0094U).
Better Formatting
CMS formatted the spreadsheet with full code names next to the code number, which is helpful. On the other hand, the spreadsheet is "locked," so you have to copy paste into a new Excel to manipulate it.
Rationales
Tab 2 is "rationales." For every code, Novitas has the same rationale (that it used a combination of reference data to price).
All the other columns of rationales are the same, for each row, but vary, between rows. These appear to be MolDx rationales, which were copied (like MolDx prices) by NGS MAC.
Differences Among MACs
The MolDx price is always the same for its participating MACs and drives the CMS Median.
NGS MAC prices (e.g. New York State) always match the MolDx price (as do its rationales).
Novitas/FCSO prices do not usually match MolDx, but are usually within a low multiple. Sometimes the multiple is 2.2X (0486U) 3X (0440U) or as high as 11X (0441U). Rarely the Novitas price is half the MolDx price (0498U, 0501U).
I've uploaded an Excel to Google Docs open access, which shows the ratios of MAC pricing to one another line by line. Here.
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| Screen shot of cloud excel of MAC ratios |
