The Centers for Medicare and Medicaid Services (CMS) on May 9 published interim pricing for 114 new molecular pathology CPT codes developed by its Medicare administrative contractors (MACs). Industry groups hope the release will trigger MAC payment to labs that have not been paid for molecular testing performed since Jan. 1.
While many of the interim prices had been released previously by individual MACs, CMS’s publication of all the prices officially launches a 60-day comment period. CMS is expected to release final pricing in September.
The pricing release also includes “gapfill rationale methodology” from five contractors—CGS, WPS, Noridian, First Coast, and Palmetto. While CMS had promised that all contractors would provide rationale methodology that would explain how they arrived at their prices, many provided no rationale whatsoever. In three of the five instances, rationale is only given for why a particular code is not covered (i.e., not medically necessary, investigational, or screening).
First Coast, one of the most recent MACs to announce pricing, is the only contractor that actually explained how it determined pricing. First Coast serves Florida, Puerto Rico, and the U.S. Virgin Islands. First Coast established six payment rules (a-f), many of which deferred to the Palmetto GBA rate or the rate suggested by the American Medical Association (AMA).
| MoPath Pricing (selected codes) |
| CPT Code, Test |
Palmetto Revised |
First Coast |
| 81210, BRAF |
$97.45 |
$60.12 |
| 81226, CYP2D6 |
$426.43 |
$505.76 |
| 81227, CYP2C9 |
$169.50 |
$73.79 |
| 81235, EGFR |
$225.00 |
$108.19 |
| 81241, F5 |
$78.39 |
$41.79 |
| 81270, JAK2 |
$82.88 |
$78.44 |
| 81275, KRAS |
$246.00 |
$156.71 |
| Sources: G2 from XIFIN and First Coast. CPT codes © American Medical Association. |
For example, First Coast’s payment rule C states, “Single source test: allow at the AMA suggested rate if available, if not allow at Palmetto rate, if there is not an established rate then allow at the 2012 stacking code rate.”
In many cases, First Coast’s pricing is below the revised prices published by Palmetto GBA in April (
NIR, 13,8/April 25, p. 1), although in a few instances it is higher.
For example, First Coast priced CPT code 81235 (EGFR) at $108.19 while Palmetto’s revised price is $225. However, First Coast priced CPT code 81226 (CYP2D6) at $505.76 compared to Palmetto’s revised price of $426.43.
Many other MACs also did not price certain CPT codes but did not provide rationale as to why they did not assign a price. In some cases, such as for the BRCA 1 and 2 tests, testing is performed by only one company and claims filed in only one jurisdiction.
Palmetto GBA, which serves California, Nevada, Hawaii, and the U.S. Pacific territories, noted in its rationale that it “applied multiple methodologies appropriate to the specific test to determine an equitable value for each submitted test.” It referred those wanting more details to its molecular diagnostic service program, which it launched last year.
Payment rates for specific codes vary widely by MACs, which had led many industry groups to question the methodologies the contractors used to arrive at prices. For example, CPT 81226 (CYP2D6) ranges in price from $50 to $505.76. CPT 81265 (STR markers specimen analysis) ranges from $123 to $470.24.
Labs and industry groups have criticized the gap-fill process for molecular pathology codes since CMS announced it late last year. Many have complained that the gap-filling process has turned into a repricing exercise when it was supposed to be a coding initiative. The groups have been lobbying lawmakers to intervene on the behalf of labs, many of which have not been paid for molecular testing since the new codes went into effect. One group reportedly is looking into legal action against CMS for failing to meet its statutory obligations.
