Molecular Diagnostic Coding, Billing, and Payment: What Does The Future Hold?

February 1, 2013

I recently attended a symposium on Molecular Diagnostics that focused on the ‘what and why’ of the new Tier coding system. The key issue as described by one of the speakers was no one had any idea of what was being paid with the stacking code system that had been being used prior to 2013. There had to be a system of transparency for payment; thus the tiered system of molecular coding. Tier 1 is specific to particular analytes such as BRAC1, etc., and Tier 2 includes master codes (81400-81408) then descriptor codes that provide detail of the test that was performed. There are also a new set of codes referred to as the MAAA (Molecular Assays with Algorithmic Analyses) codes. These codes list the specific manufacturer of any of the tests that meet the MAAA description. They can be found in Appendix O of the CPT Manual.

Then they had to decide which CMS fee schedule would be appropriate for payment of the testing. Many argued that these codes should be on the PFS due to the nature and complexity of the tests themselves. Still others argued that not every single test required the review and interpretation of a physician. Thus the debate until it was decided that the tests were to be added to the CLAB. This final rule for two reasons: 1) not each test needed to be reviewed by a physician, and 2) if they were placed on the PFS, they would not be able to be reviewed by a PhD.

Finally the pricing… this continues to be a very sticky wicket for everyone – CMS and national payers alike.  CMS decided that if the codes could be cross-walked to an existing test or group of tests, use that payment structure. If not, they would need to be gap-filled. Rarely does CMS use the gap-fill structure and never has it been implemented on a scale this grand. This is very daunting to CMS (and MACs) as gap-filling requires them to set a reasonable price for the test. What this means is that what one MAC decides is a reasonable price may be very different from another MAC’s determination. The factors used in setting rates: charges for the tests and routine discounts given to labs purchasing the tests.  The goal for CMS is to have prices published by April 2013. Bottom line is that, as of today, no one is getting paid on the new codes. The national payers are waiting for CMS before they make any moves.

The molecular diagnostic realm is moving so fast that CMS is having a hard time keeping up. Expect many changes and possible delays in code implementation and pricing for 2014.

As always, Vachette Pathology is here to answer any questions you may have. Visit our website, www.vachettepathology.com, or call us at 517.486.4262.­­­­­­­­

Michelle Miller is the Vice President of Vachette Pathology. She is an industry leader in pathology practice management, auditing, and strategizing for hospitals, pathologists, and independent laboratories.

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