MolDX Updates Tier 2 Fee Schedule

Beginning in 2013, AMA CPT began issuing several hundred codes for specific genes (such as KRAS) as well as "Tier 2" codes which are organized in 9 ascending levels of complexity and which, in total, contain over 500 gene names.

The CMS MolDX program covers a limited number of single genes by name within the Tier 2 codes.  For these, it publishes pricing.   It does not provide one blanket price per Tier 2 level, but prices its gene by name individually.  There is wide variance for the prices of covered genes within each AMA CPT mopath tier.

For 2016, the pricing was updated on the MolDX website (their table online here).  Tables and graphics after the break.



Pricing here in columns by tier (tier 1, 2, 3, etc) and the dollar values per tier listed from lowest to highest (e.g. $46 being the lowst price gene):

81400	81401	81402	81403	81404	81405	81406
46	65	98	67	95	278	384
55	76	123	67	111	379
58	90		81	148	426
58	90		83	213
64	93		93	248
64	105		93	639
70	105		98
70	106		109
82	106		135
	111		300
	120
	121
	124
	128
	128
	138
	151
	153
	163
	169
	203
	278

Average pricing per tier and standard deviation here:

Of the >500 genes listed by name by AMA CPT under Tier 2 categories, about 52 have MolDX coverage.  Actual gene names and pricing (as of February 22, 2016, MolDX document M0005, version 9):

As per Change Request (CR) 9465, CMS released the 2016 clinical laboratory fee schedule for tests reported with Tier 1 CPT codes. The table below lists the fees established for Tier 2 covered tests. Please note the genes are sorted by CPT code and then by alpha per gene. In Tier 2 codes multiple genes are listed under a single code. The required identifier assigned and submitted with each test enables MolDX to apply the appropriate fee for the specific test performed.  

HCPCS Code	Descriptor	Allowed
81400	ACE, idv	$82.58
81400	F13B, V34L	$64.52
81400	F2, 1199G>A	$70.20
81400	F5, HR2	$58.84
81400	F7,  R353Q	$64.52
81400	FGB,  -455G>A	$70.20
81400	HPA, antigen ea	$46.46
81400	IL28B, rs12979860	$55.23
81400	SERPINE1, 4G	$58.84
81401	ABL1, T315I	$153.01
81401	CYFB_MYH11, cv	$138.82
81401	CCND1_IGH, ta majbp qual qual	$93.94
81401	E2A_PBX1, ta qual quan,	$105.30
81401	EML4_ALK, ta or ia	$128.48
81401	ETV6_RUNX1, ta qual quan	$90.31
81401	EWSR1_ERG, ta qual quan	$151.42
81401	EWSR1_FLI1, ta qual quan	$162.85
81401	EWSR1_WT1, ta qual quan	$203.84
81401	F11, cv	$75.88
81401	FIP1L1_PDGFR, qual quan	$90.82
81401	FOXO1_PAX3, ta, qual quan	$120.75
81401	FOXO1_PAX7, ta, qual quan	$120.75
81401	IGH/BCL2, sbp	$123.36
81401	MUTYH, cv	$105.81
81401	PAX8_PPARG, ta	$54.19
81401	RUNX1_RUNX1T1, ta qual quan	$106.05
81401	TPMT, cv	$111.61
81401	TYMS, trv	$169.10
81401	VWF, cv (2N)	$278.18
81402	IGH_BCL2 majbp & mcr bp	$123.36
81402	KIT, cv	$98.13
81403	CEBPA, fgs	$235.54
81403	EPCAM, kfv	$93.94
81403	F8, intron 1 and 22a	$81.05
81403	IDH1, exon 4	$67.70
81403	IDH1_ IDH2, exon 4 panel	135.40
81403	IDH2, exon 4	$67.70
81403	JAK2, exon 12 and 13	$109.14
81403	MUTYH, kfv	$93.94
81403	RET, kfv	$93.94
81403	VHL , dup_del	$83.60
81403	VWF, tsa	$300.03
81404	CDKN2A, fgs	$373.14
81404	KIT, tga	$213.47
81404	NRAS, exon 1, 2	$148.04
81404	PDGFRA, tsa	$111.44
81404	PRSS1, fgs	$248.76
81404	RET, cv	$94.97
81404	VHL, fgs	$639.96
81405	MEN1, fgs	$426.32
81405	RET, tsa	$379.47
81405	VWF, tsa 2N	$278.18
81406	RET, fgs	$384.51