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CMS Asks Labs to Submit New Molecular Dx Codes Alongside Stacked CPT Codes in 2012


By Turna Ray

This story was originally posted Dec. 16.

The Centers of Medicare & Medicaid Services issued a notice last week asking labs to include the American Medical Association's new molecular pathology codes in addition to standard current procedural terminology codes when submitting claims for laboratory-developed tests starting Jan. 1, 2012.

"Medicare requests that Medicare claims for molecular pathology procedures reflect both the existing CPT 'stacked' test codes that are required for payment and the new single CPT test code that would be used for payment purposes if the new CPT test codes were active," the agency said in the notice.

The AMA's Molecular Pathology Coding Workgroup has issued two types of codes for molecular diagnostic tests — Tier 1 codes for commonly performed analyte-specific tests and Tier 2 resource-level codes describing less common tests. Additionally, the group is seeking feedback from stakeholders on a proposed coding structure for multi-analyte, algorithm-based tests developed and marketed by single labs (PGx Reporter 11/9/2011).

CMS, meantime, is still figuring out where to list genetic tests that have received new codes from the AMA: in the clinical lab fee schedule or the physician fee schedule. The agency held a meeting in July to garner stakeholder input on the positives and negatives of listing genetic test codes in one or the other fee schedule. The specific fee schedule in which a CPT code is listed has implications for how the services of pathologists and laboratory professionals are reimbursed (PGx Reporter 7/20/2011).

CMS has indicated that it will not place the new test codes into the CLFS for payment purposes until at least 2013.

Last week's notice suggests that CMS is beginning the process of incorporating the new molecular pathology codes into the reimbursement process.

"Each of these new molecular pathology procedure test codes represents a test that is currently being utilized and which may be billed to Medicare," the agency said. "If the new CPT test coding structure were active, [a lab] would bill Medicare the new, single CPT test code that corresponds to the test represented by the 'stacked' codes … rather than billing each component of the test separately."

The agency intends to use the new codes to inform claims adjudication but not for payment. CMS has a public process for setting payment levels for test codes. At the last public meeting to discuss CPT code payment levels, held in July, the agency and stakeholders did not discuss pricing for the new molecular pathology codes.

"For payment purposes under the CLFS, these test codes will be assigned a 'B' indicator," CMS said in its latest notification. This means that "there will be no [relative value units] or payment amounts for these codes and no separate payment is ever made."

Although for the time being, the new codes will not have a price attached to them, the agency is also asking labs to indicate an estimated charge, which could serve as a starting point for price negotiations. "While the allowed charge amount will be $0.00 for the new molecular pathology procedure test codes that carry the “B” indicator, Medicare requests that Medicare claims also reflect a charge for the non-payable service," the agency said.

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