Update on New Molecular Testing Reimbursement Fee Schedule
Effective January 2012, the AMA released new CPT codes for molecular tests, including HLA typing and chimerism testing routinely performed in histocompatibility and immunogenetics laboratories. Although these codes were active in 2012, CMS elected to continue to use the old "stacking" codes until January 2013. For 2013, the stacking codes were deleted and CMS determined that the new codes will be listed on the Medicare Clinical Lab Fee Schedule.
To determine reimbursement rates, CMS is using the "gap-fill" method. That methodology is seldom used, so it has been unfamiliar to the labs and the organizations that represent them. The process started with temporary gap-fill payments determined by regional contract intermediaries. Some intermediaries did not publish their gap-fill payments; for those states, no payments have been made as of yet. Preliminary national payment rates based on consideration of the temporary gap-fill fees were just published on May 9th.
Those fees that have been published by the intermediaries are, in many cases, lower than most laboratories' costs for performing the tests. For example, the published reimbursement for complete low resolution A, B, C, DRB1/3/4/5, DQB1 typing (code 81370) ranged from $123 to $552, depending on the intermediary (the higher pricing was a result of input from ASHI). Another example is the highest temporary published reimbursement rate for complete high resolution Class I (A, B, C) typing (code 81379) was $461. Although the preliminary national payment structure now published appears to use the highest of the previously published values (e.g. $552 for code 81370 and $461 for code 81379), many of those payments are still below many laboratories' costs.
The preliminary payment schedule and the rationale CMS used to prepare this can be found here:
As outlined at 42 CFR 414.509(b)(2), the public has 60 days from the posting on May 9th (that is, until July 8th) to comment to CMS about this information. The ASHI Executive Committee will work with members of the ASHI National Clinical Affairs Committee and the CPT Committee to prepare an official ASHI response, but we urge each of you to also send your own comments, as applicable. In order to be considered by CMS, comments must be received by CMS by that date. Send all comments directly to CMS at MoPathGapfillInquiries@cms.hhs.gov. You may copy your intermediary Medicare Administrative Contractors (MAC) on your comment to CMS; however, please do not comment directly to your MAC without including CMS on your submission. Please provide specific costs, test methodology, and any other information that will help CMS and its contractors review the price for a particular service code.
Note: If you are performing tests for ESRD patients and your charges are paid through published reimbursement rates for independent labs or through a cost report, this does not affect those payments. This only affects labs that bill Medicare for testing.
We urge each of you to determine if your own lab's payments received for molecular tests are tied to the new molecular test CPT codes and, if so, if your CMS reimbursement payments for molecular tests are adequate at the published levels. If they are not adequate, we would suggest that you contact CMS as outlined above. Note: the reimbursement fees are NOT method-specific. The same fee is paid for the typing listed regardless of the method or combination of methods used.
Although the intermediary listed for Texas is no longer correct, you can probably find your current intermediary here.
Meanwhile, ASHI has been working with a coalition of professional societies representing laboratorians and laboratories that perform molecular testing in an effort to obtain reasonable reimbursement for all molecular tests. The official coalition statement has been released to the media. This will be sent to various legislative and additional media contacts.
The press release can be viewed here.
The text consensus statement can be viewed here.
The temporary fee schedules published by the intermediaries earlier this year can be found here.
These were used by CMS to determine the newly published national preliminary payment schedule at the CMS link above.
For either of the payment schedules, you will need to scroll down the long list of codes to find the new molecular CPT codes of most interest to our ASHI laboratories. These codes and brief descriptors are listed here.
Please contact the ASHI office if you have any questions about these comments.
