Molecular Pathology CPT codes will be paid under the 2013 Clinical Lab Fee Schedule

Beginning in CY 2013, the Molecular Pathology CPT codes will be paid under the Clinical Lab Fee Schedule (CLFS) set by the gap filling method. CMS believes that the Molecular Pathology CPT codes describe clinical diagnostic laboratory tests that should be paid under the CLFS because these services do not ordinarily require interpretation by a physician to produce a meaningful result. In some cases, a physician interpretation of a molecular pathology test may be medically necessary to provide a clinically meaningful, beneficiary-specific result. In order to make Physician Fee Schedule (PFS) payment for that physician interpretation, on an interim basis for CY 2013, CMS has created HCPCS G0452 (molecular pathology procedure; physician interpretation and report). This professional component-only HCPCS G-code will be considered a “clinical laboratory interpretation service.” The current CPT code for interpretation and report, 83912-26, will be deleted at the end of CY 2012. HCPCS code G0452 (Molecular diagnostics; interpretation and report) will be paid under the PFS and directly crosswalked to CPT code 83912-26

Under the gap-filling method, Medicare contractors will determine reimbursement based on local pricing patterns. CMS is then expected to use the various regional reimbursement determinations to arrive at a final national reimbursement rate that would be implemented in 2014.  Also in its final CLFS ruling, CMS said that it needs to further study Multi-Analyte Assays with Algorithmic Analyses (MAAAs) codes before it can pay for them under the CLFS. “Therefore, they are instructing laboratories to continue using the existing HCPCS codes,” noting that it intends to solicit more information about this category of tests during the annual public notice process next year.