Billing Beat

2013 Gapfill Payment Amounts- Notification of Comment Period

May 20, 2013

For 2013, CMS used the gapfilling methodology to establish payment rates for the approximately 114 new Molecular Pathology CPT codes. The gapfilling process requires the Medicare Administrative Contractors (MACs) to set payment rates using a broad range of information. The MACs forwarded their interim carrier-specific payment amounts to CMS. The information is available at https://www.cms.hhs.gov/ClinicalLabFeeSched in two files:

  • one file contains the Medicare payment amounts by State and MAC number for each test code that underwent the gapfill pricing process, and
  • a second file contains the MACs’ rationale for certain tests

The public has 60 days from the date of this web posting to comment to CMS about this information. Send all comments directly to CMS at MoPathGapfillInquiries@cms.hhs.gov.  Please provide specific cost, test methodology, and any other information that will help CMS and its contractors review the price for a particular service code.

After the 60-day comment period has ended, CMS will share the comments with the MACs as part of developing final prices under the gap-filling methodology.  In September 2013, CMS will post the final gapfill pricing decisions on this web site.  These prices will be used to pay for these test codes in 2013 and 2014.  The public will have an additional 30 days to request reconsideration of any of the decisions reflected in the September file, and that reconsideration will occur during 2014.  Instructions regarding the 30-day reconsideration process will be posted on the web site along with the release of the September file.

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