Calendar Year 2015 – New Clinical Laboratory Fee Schedule (CLFS) Test Codes and Final Gapfill Payment Determinations

Last week CMS released preliminary pricing determinations for 2016 for a number of lab tests described by new CPT codes, as well as several multi-analyte algorithm-based assays (MAAA). CMS determines lab test pricing using the so-called gapfill process, when no comparable technology exists, or the crosswalk method, which correlates payment to rates for comparable technologies and CPT codes. For the majority of MAAAs that the government payor considered, it used the crosswalk method, spurring objections from labs that pricing using this process fails to capture the value of their tests. The biggest surprise is the unexpectedly low reimbursement rates proposed to be assigned to the 4 tiers of drug screens that are 30% + lower than the reduced rates currently assigned by Palmetto GBA. Labs can appeal initial CMS pricing within 60 days, and final changes will go into effect on January 1, 2016.The public is invited to submit requests for reconsideration of the final pricing decisions.  Please submit any reconsideration requests to glenn.mcguirk@cms.hhs.gov by October 26, 2015.

Source: https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/ClinicalLabFeeSched/Gapfill-Pricing-Inquiries.html