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Insights

Oct 10, 2013

CMS Solicits Comments on Revised 2013 Gapfill Payments for MolDx Tests and Denies Payment for MAAA Codes

Published

Oct 10, 2013

On September 30, CMS posted revised gapfill prices for molecular pathology Current Procedural Terminology (CPT®) codes, including calculations of the 2014 National Limit Amounts (NLAs).

The NLA is equal to the median of all Medicare Administrative Contractor (MAC) rates and is the highest price Medicare will permit for a particular genetic test effective on January 1 of the following year.  Last May, CMS released an initial pricing list of 114 codes, though in the most recent update they only included payment amounts for tests that are currently being paid for by MACs. As a result, approximately 49 molecular pathology CPT codes were omitted from CMS’ revised list.

Molecular tests that were not valued and are not paid by any MAC may experience some difficulty in obtaining coverage and payment for their test, from both Medicare and commercial/Medicaid payers. Many third-party payers will likely follow Medicare’s published rates to establish or revise their own payment rates and coverage policies for molecular tests in the coming year. As such, reconsideration requests will play a critical role in encouraging CMS to publish rates for these codes.

CMS is currently accepting public comments on their revised molecular pathology payment list until October 30.  If CMS decides to update a NLA as a result of comments from the reconsideration process, then the revised NLA will be effective for 2014 and beyond. It remains unclear whether the gapfill process will remain open for the codes that were not valued. 

See more information about the revised list and its associated comment period. 

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