If you have been following Medicare’s consideration of payment rates for the new molecular pathology CPT codes and are confused, don’t feel alarmed; CMS has proposed two substantially different methodologies using two different fee schedules, let alone pricing methodologies.
The tests will be paid through either the clinical lab fee schedule (CLFS), as under current policies, or through the physician fee schedule (PFS). Each fee schedule would continue to be administered as they currently are with no beneficiary cost sharing on the CLFS and the 20% fee sharing required under the PFS.
Price setting under the CLFS will follow the cross-walking and gap-filling process used in the past. This process will be aided by the current year procedure of filing both the new CPTs (which are not currently paid) and the old CPTs (which are paid). Price setting under the PFS would be delegated to Medicare contractors since “the price of these tests can vary locally and we (CMS) do not believe we have sufficient information at this time to engage in accurate national pricing.”
The final determination as to the fee schedule and pricing methodology to be used will be announced in the November 1, 2012 PFS final rule. It is even possible that CMS will decide not to decide and leave the current payment rules in place. Items to be considered by CMS in the rate setting process include location and batching of such testing, physician involvement and projected utilization.
We will continue to follow this discussion and will update clients as to the results as they become available.
Los Angeles, CA