There was a period in the "old days" - let's say, 2013, 2014, 2015 - when MACs were offered a list of gapfill codes to be priced in the first quarter of the new calendar year, and MACs priced them if they wanted to. Some MACs priced few of them, for example, if there was no utilization.
Beginning several years ago - I'm guessing, maybe 2016 or 2017 - CMS began requiring that MACs price ALL codes in the gapfill process. This has gotten increasingly complex as 30, 40, or more codes enter the first quarter gapfill process.
This year, CMS has released transmittals with new codes, gapfill notifications, etc. Worth knowing about - January 20, 2021, MM12080 here, and CR12080 T10575, here.
At several points, this transmittal states that "MACs shall only price PLA codes for laboratories within their jurisdiction."
I couldn't tell for sure if this statement applies to each rolling batch of new quarterly PLA codes, or if this ALSO is meant to apply even to the annual list of required nationwide MAC Gapfill pricing decisions for the new year.
For example, CMS might say, "Here are six new PLA codes for this quarter, only price them if they are used in your MAC," but in contrast say, "Here are 42 new codes to be gapfilled nationwide for CY2021, please price all of them."
>> (Update). A policy expert at CMS said this interpretation was correct - incidental PLA codes on a rolling basis don't have to be priced by MACs, but the annual national gapfill list is supposed to be filled out completely by all MACs.
(Still, at least one real-world MAC was confused by the instructions.)
Additional rules are in the transmittal, such as changes in COVID PCR test pricing for CY2021 and implementation of an add-on payment for rapid testing.
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Nerdy Details
Nerdy Details
There have been several nerdy changes to PAMA law, with the result that claims data from 1H2019 will be reported to CMS in January 2022, for a three year pricing period 2023, 2024, 2025. Since the next new 3-year fee schedule will be CY2026, I believe the next data collection will be 1H2024, reported to CMS in 2025. There are still some price reductions underway in a staged fashion from the 2018-2019-2020 fee schedule. There are 0% changes 2020>2021, but there may be a 15% per year reduction 2022, 2023, 2024. (Relatively few tests are still getting reductions, but some are. Also, there were a few quirky PAMA results such as a rare $75 test with a new $1 price, so its phased reductions would go on for a long time.)
Due to some quirk in lab law, on January 1, 2021, there was a 0.2% update to the Clin Lab Fee Schedule which applies only to Pap Smear tests, and resets their price floor from $15.12 to $15.15, three cents.
CMS lists new codes coming into use from October 6 forward, in this transmittal, as well as the list of all new codes for 1/1/2022. For 80,000-series codes (e.g. 87637) CMS states the codes are contractor priced where applicable "until they are nationally priced." For PLA codes appearing on a rolling basis, CMS remarks they need only be priced by the MAC having that jurisdiction.
In long tables at the back of CR12080, CMS lists new codes for 2021 as either crosswalked or "gapfilled" up to 0220U. Higher codes appeared after the June 2020 "crosswalk/gapfill" meeting, and are described in a following table as "contractor priced" (not "gapfilled") until pricing is assigned at the June 2021 lab policy meeting.
