Payment, Processing Anxiety Over MDx Code Gap-Fills

Despite speculation in some industry circles that its implementation might be delayed, the gap-fill method remains the approved process whereby local Medicare contractors determine the payment rates for 114 molecular pathology codes new to the 2013 Part B clinical lab fee schedule, effective Jan. 1. This has triggered anxiety among pathology practices and independent clinical laboratories for several reasons. Does this give local contractors enough time to calculate reasonable payment rates based on pricing patterns in their jurisdiction? Will this delay processing of 2013 claims for these codes and thereby disrupt providers’ cash flow? The new codes are arranged in two tiers: Tier 1, CPT 81200-81383, for analyte-specific, high-volume tests, and Tier 2, CPT 81400-81479, for resource-based, low-volume procedures. They replace the stacking codes, CPT 83890-83914, that have been eliminated in 2013. The Centers for Medicare and Medicaid Services (CMS) said it adopted the gap-fill method because it did not have sufficient information to set national payment caps for these codes in 2013. But the agency said it would tap pricing data from local Medicare contractors to establish national fee caps for these codes in 2014. Gap-filling is one of two approved methods that CMS uses to establish payment rates for tests covered under the Medicare lab fee schedule. It is used when there is no comparable crosswalk to an existing code or set of codes. It is rarely used and only for new tests with low volume initially and that Medicare has not covered in the past. Gap-filling requires local contractors to set their Medicare rates based on several factors in their jurisdictions, such as the cost of the testing, charges for it after discounts, and reimbursement rates set by other payers. “Until local contractors complete the gap-filling process, clinical labs may not be paid for molecular pathology tests with the new CPT codes,” the American Clinical Laboratory Association has warned. The impact of gap-filling has been minimal in the past “because new tests typically have low claim volumes. In contrast, here, gap-filling would be used for well-established and frequently ordered tests.” One local contractor, Palmetto GBA, which handles claims for California, Nevada, Hawaii, and the Pacific territories, has already announced that for services on or after Jan. 1, the Tier 1 and Tier 2 codes will be included in its controversial MolDx program, requiring labs to register each assay and, if applicable, get a McKesson Z-Code identifier in order to bill and be paid.