Statement on Revised Gapfill Pricing of the Molecular Diagnostic Codes

October 01, 2013 Categories: ACLA News, All News, Reimbursement and Coverage

Statement on Revised Gapfill Pricing of the Molecular Diagnostic Codes
October 1, 2013

Washington, DC – The American Clinical Laboratory Association (ACLA) issued the following statement on the Centers for Medicare & Medicaid Services’ release of the revised gapfill pricing of the molecular diagnostic codes:

“On September 30th, the Centers for Medicare & Medicaid Services released the final carrier prices for the new molecular diagnostic codes, describing existing tests, which were added to the clinical laboratory fee schedule January 1, 2013. These are the prices that resulted from the ‘gapfilling’ process that CMS initiated earlier this year.

“There were prices published for only 65 of the 116 total codes that were to be priced under the gap‐filling process laid out in the Code of Federal Regulations (42 CFR 414.508(b)), leaving much uncertainty over the status of the non‐priced codes.

“The American Clinical Laboratory Association (ACLA) is still in the process of reviewing the information that was published yesterday, but has received several credible reports that there may be clerical errors in the published information that could impact the final pricing for these tests.

“Furthermore, ACLA is greatly concerned about statements by CMS that carriers who priced a code below the national limitation amount (NLA) could continue to reimburse for the code at that lower rate after January 1, 2014 when the NLA is to take effect. This statement is inconsistent with the clear language of the gap‐fill regulations, which states that after the first year payment for gapfilled tests is made at the NLA amount. ACLA plans to discuss these issues with officials at CMS as soon as possible, after the current government shutdown is resolved.

“Molecular and genetic testing represent the forefront of diagnostic medicine and ACLA is committed to advocating for fair and sustainable reimbursement rates for this invaluable class of highly advanced tests.

“ACLA will continue to analyze the data, and looks forward to the opportunity to clarify some of the uncertainty and apparent contradictions.”

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