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AMA Molecular Pathology Group Nears Finalizing New CPT Coding Structure for Molecular Dxs

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Originally published June 11.

By Turna Ray

At a meeting last week of the American Medical Association's CPT Editorial Panel, stakeholders inched closer to developing a new coding structure for molecular diagnostics and genetic tests.

The AMA maintains Current Procedural Terminology, or CPT, codes through its CPT Editorial Panel. In order for healthcare providers to bill insurers for medical, diagnostics, or surgical procedures, they must use CPT codes published by the AMA to describe the work performed.

At an earlier meeting of the CPT Editorial Panel's Molecular Pathology Workgroup, stakeholders had proposed forming a two-tier coding system for genetic testing and molecular diagnostics. The first tier of codes would be for the most utilized tests, including pharmacogenetic tests for warfarin sensitivity, KRAS testing in colorectal cancer, tests for cystic fibrosis, and others.

The second tier of codes would base payment on the number of exons a particular test analyzed within a gene. For example, Myriad Genetics' BRACAnalysis test for hereditary breast and ovarian cancer would likely be reimbursed by this second tier of codes (PGx Reporter 03/17/10).

At the most recent meeting, the workgroup expanded the number of codes to be included in the first tier from a handful to as many as 150 codes, comprising codes for high-volume PGx tests and tests for uncommon genetic diseases, Pharmacogenomics Reporter has learned.

Although meetings of AMA's CPT Editorial Panel are open to the public, the AMA requires stakeholders to sign a confidentiality agreement. As such, PGx Reporter has gathered this update from sources knowledgeable of what went on at the most recent meeting, but who have chosen to remain anonymous.

The CPT Editorial Panel is slated to decide whether to incorporate the molecular pathology workgroup's coding recommendations by Dec. 31, 2011. Since the new coding structure is still very much a work in progress, there is no guarantee that any of the current ideas in play will be finalized. The next meeting to discuss and potentially finalize the new CPT coding structure of genetic tests is scheduled for Oct. 14-16 in Los Angeles. The new coding structure is expected take hold in 2012.

Jeffrey Kant, the Association of Molecular Pathology's economic affairs committee chair, previously discussed with PGx Reporter some broad issues related to the current CPT coding structure, but declined to confirm that AMA is considering implementing a two-tier coding structure. AMP has issued a set of coding recommendations to AMA in a white paper, and is among several stakeholder groups involved in AMA's meetings on the subject.

However, Kant did note that any new structure put in place would have to account for single-lab, multi-gene tests, such as Agendia's MammaPrint and Genomic Health's Oncotype DX. How the new coding structure would accommodate such tests has yet to be decided. Kant did not return an e-mail request for an interview.

A source close to the issues noted that there was much discussion and hand-wringing at the most recent meeting with regard to these so-called "boutique tests," but a single proposal has not been agreed upon yet.

Industry stakeholders have often criticized the fact that current CPT codes don't accurately describe the complex procedures performed as part of advanced molecular diagnostics and genetic tests. This may negatively impact how much test developers are paid.

Simultaneously, payors have complained that they often don't know what they are reimbursing for due to the practice of "stacking" CPT codes, in which healthcare providers use multiple existing CPT codes for a diagnostic when there isn't a single code to describe the procedures involved in a test.

By developing a new coding structure, AMA is attempting to more accurately describe molecular diagnostics and genetic tests, so payors have a better sense of what procedures are being performed and what they are paying for.

The healthcare information technology provider McKesson estimates that currently only 21 relevant codes exist for more than 1,500 molecular diagnostic tests. McKesson is among the stakeholders involved in discussions with the AMA regarding the new CPT coding structure.

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