April 2021 Update of the Hospital Outpatient Prospective Payment System (OPPS)

Advanced Diagnostic Laboratory Tests (ADLT) Under the Clinical Lab Fee Schedule (CLFS) Under the OPPS, tests that receive ADLT status under Section 1834A(d)(5)(A) of the Social Security Act (the Act) are assigned to status indicator A (Not paid under OPPS. Paid by MACs under a fee schedule or payment system other than OPPS).

In the October 2019 update to the OPPS (CR 11451, Transmittal 4411, dated October 4, 2019), CMS indicated that the Decision DxMelanoma test was approved for ADLT status on May 17, 2019. However, because there was no specific code to describe this test, CMS revised the status indicator for CPT code 81599 from E1 (Not paid by Medicare when submitted on outpatient claims (any outpatient bill type.)) to A, so that this laboratory test would be paid separately under the CLFS when reported with identifier ZB1D4.

 

For the 2021 update, the CPT Editorial Panel established CPT code 81529 (Oncology (cutaneous melanoma), mrna, gene expression profiling by real-time rt-pcr of 31 genes (28 content and 3 housekeeping), utilizing formalin-fixed paraffin-embedded tissue, algorithm reported as recurrence risk, including likelihood of sentinel lymph node metastasis) to describe the DecisionDx-Melanoma test effective January 1, 2021.

Because the DecisionDx-Melanoma test is now described by CPT code 81529, CMS is revising the status indicator for CPT code 81599 back to E1. CMS is also including this change in the April 2021 I/OCE Release with an effective date of January 1, 2021.

Note: CPT code 81529 is assigned to OPPS status indicator A, effective January 1, 2021.

Source: https://www.cms.gov/files/document/mm12175.pdf