The Topsy Turvy World of Medicare Genetic Pricing

Currently, as the CY2016 gapfill year proceeds, Medicare's pricing for genetic testing contains some topsy-turvy extremes and marked regional variation in how CPT coding conventions are applied.

While several examples could be provided, the most eye popping variations occur in the field of BRCA testing and hereditary breast and ovarian cancer gene panel testing.

The original codes in this field are for BRCA1 & BRCA2 testing "including common dup/del variants," 81211, with a CLFS price of $2180.22; and "uncommon dup/del variants," 81213, with a CLFS price of $581.84 (together, $2762.06).

Last year's new code consolidated these two codes into one, 81162, BRCA1 & BRCA2 full sequence analysis with full dup/del analysis, priced at $2485.86.

This year's new code set is for a gene panel including BRCA1 & BRCA2 and several other genes contributory to hereditary breast cancer.  This is code 81432.   It has a paired code for dup/del analysis, 81433.   While Medicare won't finalize gapfill pricing until November 2016, the current public gapfill median prices are $622.53 and $159.48, respectively (together, $782.01).

Regarding the latter code, the MolDX program operates in some 25 states now, and according to the current MolDX website, 81433 is a nonpayable code (do not pass go, do not collect $159.48).

This is best displayed visually.   If you perform BRCA 1 and BRCA 2 testing AND MORE GENES, the price drops by 75%.   If you perform the HBOC panel testing on different days, or by stack coding, pricing could probably exceed levels of $3000 to $4000 at CLFS line item prices.   If you live in a MolDX state, perform one panel, and code per AMA and MolDX instructions...you get $622.  See chart, and remember the test panels on the right are more genes, more work, more reporting, and more clinical utility:

Click on image to enlarge.

Relief from the craziness may be in sight.

More and more frequently (based on public information from public companies), this gene panel testing is rapidly being consolidated into pan-cancer panels, e.g. the Myriad MyRisk test and others.  According to the company, which is the largest provider of hereditary risk testing at some $600M per year, "We completed the conversion to myRisk among our targeted physicians and have made gene panel standard of care within the marketplace" (August, 2016).

Checking on the public agenda for the September 28-29 AMA CPT meeting, a corresponding multi syndrome hereditary testing cancer code as been proposed (Tab 52).  Sounds like it is time.