For several years, the AMA CPT has released public agendas of codes-in-play prior to their public CPT editorial panel meetings. After the meetings, the AMA CPT also releases a summary of decisions made.
The agenda for the February 2017 meeting is here. [Link will change if updated; see main page here.]
Several codes address hereditary risk testing.
According to Tab 18, there is a proposal to revise BRCA1/BRCA2 codes 81121 and 81162. The former is a legacy code for BRCA sequencing, priced by CMS at about $2195 for CY2017. The second code includes a composite of BRCA sequencing and dupdel analysis, priced by CMS at about $2503. These BRCA sequencing codes contrast sharply with a newer panel codes, that currently includes BRCA1/BRCA2 sequencing AND 12 or more additional breast and ovarian cancer genes. This code, 81432, is priced by CMS at $931. In payer circles, this is called a "rank order disparity" in pricing - a code that involves more work, including the same work, is priced far lower than another code. According to tab 18, 81121 would be defined for Sanger sequencing and 81162 would be defined for next gen sequencing.
Tab 21 is related to the hereditary breast cancer "panel" code, 81432, $931. It is currently defined to include an EXACT gene panel set, suggesting if any one gene is left out, the panel code at $932 will not apply. Absent a panel code, labs would presumably use unlisted codes or stack individual gene codes, which could total to circa $4000. Tab 21 suggests revising the code to always including BRCA1 and BRCA2 and to encompass 10 or more genes "typically including" a gene set, so that if one or two genes were left out or substituted, the panel code might still apply.
Finally, according to the agenda, Tab 22 is Genomic Sequencing Procedure for Multiple Cancer Syndromes. This would be germline hereditary panels that include genes selected from among multiple cancer syndromes. If accepted, such a code would enter the next CMS gapfill/crosswalk pricing process. Since the AMA CPT doesn't appear to have a clear rule in the text about when stack coding should stop and an unlisted code should be used, in the absence of this new code, there would either be a lot of use of high level stack coding or high use of unlisted codes (which tallied 1/3 of Medicare's molecular payments in CY2015!!!!).
In a webinar sponsored by PMC and AHIP on December 15, a major payer described frequently getting genetic stack code claims with 20 or more codes submitted. In the case of BRCA testing under codes 81211, 81162, 81432, bringing the coding together with CMS fee schedules, in some cases Medicare may be paying $932, in some cases $2300 or more. President Trump would probably tweet - "Bad deal - must change!"
