AMA Quickly Issuing, Pricing New Proprietary Analyses Codes, but Will They Improve MDx Reimbursement?

The AMA has been rapidly issuing a new set of CPT codes at the request of test makers that want to more specifically track the use of their diagnostics for reimbursement purposes. The AMA CPT Editorial Panel last year began approving so-called Proprietary Laboratory Analyses (PLA) codes in response to CMS requirements for implementing the Protecting Access to Medicare Act (PAMA). The AMA began accepting applications last year from test makers that want PLA codes, and over the past months it has issued 23 codes. A substantial number of these tests with PLA codes have even entered the gapfill and crosswalk process to determine pricing. As long as test makers develop and perform the test in the US, it seems they can get a PLA code. Tests don’t have to meet usage or volume criteria required for other CPT code types, such as Tier 1 and Tier 2 molecular pathology codes or multi-analyte algorithm-based assays codes. Because recently issued and priced PLA codes will show up in the new 2018 fee schedule, it’s conceivable that some payors would default to reimbursing for them as they did when codes for pharmacogenomic tests first entered the fee schedule.