Header: AMA CPT has created some new Category III codes for whole-slide imaging proprietary tests. However, as of May 26, CMS has NOT added these clinical laboratory codes to the summer CLFS pricing process. What happens to Category III codes in terms of MAC pricing?
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CMS assigns RVU-based national prices to nearly all AMA CPT codes in Category I (aside from clinical laboratory tests). However, one counter-example is PET-CT, which does have fixed, national prices for physician interpretation (around $100) but there is no national Part B price for the technical component, or for the global service (meaing, scan + interpretation) in the non facility setting.
In the facility setting, Medicare sets a hospital outpatient rate (about $1400 for 78815, varies with geography). This is via the ambulatory payment classification (APC) of code 78815 under OPPS policy.
In the non-facility setting, where >800,000 PET CT scans are performed, MACs set prices for 78815 for the technical component (or the global claim).
For comparison, CMS pays about $1400 for the technical component of 78815 PET CT in the hospital outpatient setting (with regional adjustments.)
What's it mean?
First, it's tricky, since the Part B database I'm pulling from lumps together all forms of Part B 78815 payment (whether PC only, TC only, or global).
California TC Can Be Rationalized. MAC behavior when freed from RVU pricing is confusing. Generally, the maximum Part B RVU delta in low to high priced areas is +50% of the base RVU rate (e.g. for 88361, computer assisted IHC, TC or global).
This +50% geographic hike for priced RVUs across geographies would lift the $1400 hospital outpatient APC to the $2000 range, exactly what we see in California. So it's reasonable to guess that Noridian used the APC price of $1400 and the regional multiplier (in SF, LA, etc) of +50% to get around $2000.
Payments $200-900 Seem Damn Odd. It's unclear how you get the prices between $200 and $1000.
- If these are TC alone, the prices seem "too low," at least, compared to the APC benchmark of $1400.
- On the other hand, if these are professional component alone, it should be impossible to pay over the $100-150 range due to fee schedules for 78815-26.
Take-Home Lesson for WSI Codes
Based on AMA CPT Summary of Panel Actions documents, at the February Palm Springs meeting they created two WSI codes (X568T, X569T), final code text to be released 7/1/2026. At the May Boston meeting, they created additional WSI codes for breast and prostate cancer respectively (X623T, X624T), I believe also to be released 7/1/2026.
If CMS continues to leave these "off" the summer lab meeting schedule, then they will be included in summer policymaking for the Hospital Outpatient (OPPS) environment, and assigned to pathology category prices or new tech category prices for OPPS.
MACs may use these Category III OPPS prices as reference prices for Category III codes in Part B, just like MACs used the APC price $1400 for 78815 as a reference price for Part B.
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Sidebar:
Using Chat GPT for Data Analysis
I downloaded all Part B payments for 78815, PET CT, for CY2024.
I asked Chat GPT to compare pricing >$1978 with pricing in the band $909-1197 (low, but believable for TC).
Over $1978
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$909-1197
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Chat GPT adds this text:
The contrast is striking. The high-payment band is not a general national distribution; it is dominated by California, with a bit of New York. The low-payment band is much more of a multi-state pattern, led by SC, OH, FL, MN, TN, and scattered others.
Both bands in the spreadsheet are Place of Service “O” lines, so this comparison appears to be within the office/nonfacility physician-supplier world, not hospital outpatient OPPS. That makes the spread more interesting: for 78815 technical/global office PET/CT, allowed amounts are not converging around a single national TC price. Instead, the data look like a patchwork of MAC/locality/carrier-priced technical-component behavior, with California standing out at the high end.
The policy takeaway is that although the physician interpretation of 78815-26 is nationally PFS-priced, the nonfacility technical economics of PET/CT remain quite variable. In this slice, the high band is roughly double the lower band: about $2,183 weighted average versus $1,073 weighted average. That is a large swing for what is nominally the same PET/CT skull-base-to-mid-thigh service.
