NEW YORK (GenomeWeb) – The American Medical Association's CPT Editorial Panel will be discussing revisions to a number of molecular pathology codes at its February meeting, including codes describing testing for BRCA1 and BRCA2 genes.
The panel's decisions, which will be made public after the meeting, will provide guidance regarding the codes diagnostic companies can submit to payors for test billing, which in turn, has revenue implications.
According to a recently released agenda, the panel will consider revising the legacy BRCA sequencing code, which the Centers for Medicare & Medicaid Services has priced at around $2,200 (CPT code 81211) and the code for BRCA sequencing with duplication and deletion analysis (CPT code 81162) priced at $2,500. The CPT Editorial Panel is considering specifying that the first code should be used when Sanger or capillary sequencing has been performed, and the second code when massively parallel, or next-generation sequencing is used.
Medicare contractors and payors don't speak with one voice with regard to when Tier 1 and Tier 2 analyte-specific molecular pathology CPT codes, unlisted procedure codes, and newer NGS panel codes should be applied.
Through its MolDx program, Medicare contractor Palmetto GBA has said it "considers an NGS panel a single test with multiple potential indications," and instructed labs to not report NGS tests with Tier 1 or Tier 2 CPT codes that describe testing for one or two genes, "even if a single gene or multiple genes are selected for testing." Palmetto said it will deny NGS panels reported with Tier 1 or Tier 2 codes. But not all Medicare contractors have this policy, so labs are employing different coding strategies.
As noted by national reimbursement expert Bruce Quinn on his blog, the prices of legacy BRCA codes "contrast sharply" with newer codes for NGS panels that gauge multiple genes. "Absent a panel code, labs would presumably use unlisted codes or stack individual gene codes, which could total to circa $4,000."
For example, Myriad Genetics has said it has arrangements with payors that allow it to bill for its myRisk Hereditary Cancer panel using legacy billing codes and market analysts estimate the company is getting paid more than $2,500. Meanwhile, Invitae uses CPT code 81432 for NGS panel testing ― currently priced by CMS at around $930 ― in line with guidance from Palmetto GBA's MolDx program.
As Quinn pointed out, CPT code 81432 for hereditary breast cancer panel testing is currently viewed as a code that can only be used if all the described genes (BRCA1/2 and 12 others) are analyzed. But the CPT Editorial Panel is considering revising this code description at its next meeting so it can be used when at least 10 genes are assessed. Within this panel, however, BRCA1/2 must always be tested. This suggests that "if one or two genes were left out or substituted, the panel code might still apply," according to Quinn.
Lastly, the CPT Editorial Panel is also considering pricing a new code for germline hereditary cancer testing panels for multiple cancer syndromes.