CMS Releases Preliminary CLFS Payment Methodology for MDx Tests

On Friday, Aug. 31, CMS said it recommends using gap-fill methodology for pricing of molecular pathology procedures paid under the clinical laboratory fee schedule (CLFS). Final payment determinations will be announced in November. CMS held a public meeting in July to get input on pricing of these codes as well as the 16 new CPT codes to be added to the CLFS as of Jan. 1, 2013. In the Aug. 31 announcement, CMS said it did not have enough information to price the new tests using crosswalking methodology. Under this method, a new test code is matched to a similar code, multiple existing codes, or a portion of an existing code and is paid at that rate. The gap-fill alternative is used when there is no comparable existing test. Local contractors set the fee for the first year, based on local pricing patterns. Because the same molecular test is often billed using different stacks and the stacks may have changed over time, CMS is recommending that the new MDx codes be gap-filled for 2013. This will allow CMS and its contractors the opportunity to gather current information about the manner in which the tests are performed and the resources necessary to provide them so that CMS can set an appropriate payment rate for these tests.

CMS’s Aug. 31 announcement is available here:
https://www.cms.gov