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CAP Urges CMS to Publish Recommended Payment Values for Molecular Dx CPT Codes


Originally published Jan. 8.

The College of American Pathologists is urging the Centers for Medicare & Medicaid Services to publish physician payment values that the group has recommended for molecular diagnostic claims codes developed by the American Medical Association.

The AMA last year issued more than 100 current procedural terminology codes for molecular diagnostic tests, split into two categories: Tier 1 codes for commonly performed analyte-specific tests and Tier 2 resource-level codes describing less common tests (PGx Reporter 3/16/2011). However, CMS hasn't included these codes in either its clinical lab fee schedule or its physician fee schedule for 2012.

In the meantime, CAP has developed physician work relative value unit (RVU) recommendations and practice expense inputs for 79 of the new AMA codes.

The AMA’s Relative Value Update Committee "reviewed and agreed with these recommendations (with minor edits), and forwarded them to CMS in May and October of 2011. However, in the final rule CMS did not publish RVUs for these new CPT codes in the 2012 PFS, and therefore they will not be valid for Medicare purposes for [calendar year] 2012," CAP President Stanley Robboy wrote in a Dec. 21, 2011, letter to Marilyn Tavenner, CMS's acting administrator.

The pathologists' group would like CMS to "immediate[ly] accept … the [AMA committee's] recommendations and payment of these critical diagnostic services."

In a letter to Tavenner last month challenging CMS's new claims processing criteria for lab tests reimbursed by Medicare contractor Palmetto, AMA Executive VP James Madara lodged a similar complaint about the agency's failure to publish the committee's recommended RVUs (PGx Reporter 1/4/2012).

"At the specific urging of Medicare, the [AMA's Relative Value Update Committee] reviewed the physician time, work, and direct costs for all of the molecular pathology codes that were identified to have direct physician involvement," Madara wrote. "Throughout this process, CMS indicated that the data was needed for rule-making for the 2012 Medicare Physician Payment Schedule. We are, therefore, deeply disappointed that CMS did not consider this information in the Final Rule."

CMS issued a notice in December asking labs to submit claims for lab-developed tests with stacked codes as well as the new CPT codes developed by the AMA. Although for the time being, the new CPT codes will not have a price attached to them, the agency is asking labs to indicate an estimated charge, which could serve as a starting point for price negotiations (PGx Reporter 12/21/2011).

The fact that the new CPT codes aren't included in the current PFS or CLFS ensures that the practice of stacking CPT codes for molecular diagnostics will continue for the coming year.

CMS's failure to publish the RVUs "has astonished all healthcare providers and payers, as bringing these new services to the forefront of medicine was viewed as a tremendous cooperative undertaking by the entire healthcare industry," Robboy wrote in CAP's letter, adding that the organization "disagrees with this decision as it denies payers a modern cost-saving methodology for reimbursement."

Payors believe that the longstanding practice of stacking CPT codes obscures which procedures are being performed by healthcare providers and, subsequently, the specific services that they reimburse. This lack of clarity in payment policy, from a payor perspective, contributes to unnecessary healthcare spending.

Meanwhile, test makers believe that the payment rates attached to older CPT codes they currently bundle and submit to payors don't capture the value these complex tests provide to healthcare. Furthermore, the pathology community believes that CMS is delaying adoption of new molecular diagnostic tests by not setting physician payment levels on the new molecular diagnostic CPT codes.

"The CAP, and every payer who has a history with these services, strongly believes the 'stacking' code methodology is extremely antiquated and the new CPT codes superior," Robboy notes in the letter. "The highest volume codes are analyte specific, which allows payers to determine what service is actually being performed, in contrast to the stacking codes, which are methodology based. More importantly, the CAP considers CMS’s decision a huge barrier to patient access for these services."

Finally, CAP believes that in failing to publish the payment value recommendations, CMS is flouting existing policy, which requires it to publish RVUs for services in cases where recommendations have been made to the agency. "If … CMS is not ready to implement the new molecular pathology CPT codes at this time, the CAP urges CMS to immediately publish the relative values for these molecular pathology services so that other payers and providers may use these codes," Robboy wrote.

In addition to criticizing CMS's actions regarding RVUs for new molecular diagnostic CPT codes, Robboy asked CMS to repeal the sustainable growth rate — a formula the agency uses to calculate payment rates to doctors for services treating seniors. Absent Congressional action, physicians face a cut in reimbursement rates of more than 27 percent this year for such services. Furthermore, CAP in its letter also asks CMS to identify and review "potentially misvalued services."

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