UPDATE: CMS POSTS THE ACTUAL NEW "R2" RULING, EFFECTIVE DATE AS 1/1/2021:
https://www.cms.gov/files/document/cms-ruling-2020-1-r2.pdf
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Initially this year, CMS paid $51 for COVID testing. In April, CMS announced high-throughput codes that would be priced higher, at $100, to encourage investment, development, and rapid expansion of test resources. This $100 price was announced via an Administrator's Ruling on April 14 - here.
On October 15, CMS announced a new policy that will pay $100 only for two-day turnaround of results. Otherwise, even high-throughput testing will be discounted to $75 beginning January 1.
CMS made the announcement in a press release - here.
- CMS watchers will recall that Seema Verma flagged that some major change in COVID pricing was coming in a speech one month ago, on September 17 (news report here).
On Friday, CMS also posted the actual 10 page ruling - here. This refers multiple times to 2 days time, relative to the specimen being COLLECTED (not accessioned at the lab door, as some labs hoped).
CMS argues that the full $100 payment for intensive resources and staff are only applicable in a lab that is resourcing fully for 48 hours turnarounds.
CMS estimates that the costs ($100) associated with high throughput technology, hiring staff, and other resource costs, are only incurred when laboratories complete the majority of molecular genomic CDLTs that make use of high throughput technology for the detection of SARS–CoV–2 or diagnosis of the virus that causes COVID-19 within 2 calendar days of specimen collection for all patients, not just for a subset of patients.
According to the press release, the upcoming R2 will leave the existing codes intact, reduce the $100 price to $75, and create a new code U0005 for a $25 supplement.
In an interesting twist, while the CMS payment will apply only to Medicare payments, the payment of $25 will be given for Medicare patient IF the lab had two day turnaround time on "THE MAJORITY OF ALL" of its COVID testing in the previous month. This seems to be written as an "AND" clause, see quote below, so the test for a certain Medicare patient this month must be in two days, AND ALSO, the tests for all patients in the previous month must (in the majority) be made in two days. However, I'm not sure that the syntax, which is repeated after the (a)/(b) statement, is perfectly clear. Clipped below.
Not that this applies only to Medicare FFS patients (Traditional Part B); some experts think that in a few years this will only be half of Medicare patients, the rest being under Medicare Advantage.
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CMS writes,
"Starting January 1, 2021, the amended Administrative Ruling (CMS 2020-1-R2) will lower the base payment amount for COVID-19 diagnostic tests run on high-throughput technology to $75 in accordance with CMS’s assessment of the resources needed to perform those tests. Also starting January 1, 2021, Medicare will make an additional $25 add-on payment to laboratories for a COVID-19 diagnostic test run on high throughput technology if the laboratory:
a) completes the test in two calendar days or less, and
b) completes the majority of their COVID-19 diagnostic tests that use high throughput technology in two calendar days or less for all of their patients (not just their Medicare patients) in the previous month.
Laboratories that complete a majority of COVID-19 diagnostic tests run on high throughput technology within two days will be paid $100 per test by Medicare, while laboratories that take longer will receive $75 per test."
