Log on to the Palmetto MolDx Diagnostics Exchange this week, and you'll see this splash screen:
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(To get into the DEX website, you need to log on with an email and create a password).
The Price Field
If you look up a lab test, there will be a new field, in "beta," which is the price.
- For some tests, the field says "See Fee Schedule."
- In some cases, like PGx panels, you have no idea what the coding is, so an instruction "see fee schedule" is not informative.
- Generally, when a test is not covered by MolDx, it does not show a price.
The Coverage Field (Bottom)
For some tests but not others, MolDx also lists a data section called "Coverage." This will state a test is covered by Medicare, or not, but sometimes it is blank and sometimes the "Coverage" field is simply not there. MolDx informed me that this depends if the test originally got a Z code with the intent to have coverage, or registered solely for a Z code. In the latter case, the Coverage tab at the bottom is missing and gives no information either way.
Example: Allosure Coverage and Pricing Look-Up
Let's take a simple example of the database in use. The CAREDX ALLOSURE test is code by generic code 81479. It's covered by a MolDx LCD. The price field gives a price for ALLOSURE. ($2,840).
Down at the bottom, there is a tab for COVERAGE and it is stated to be covered.
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In an early version of this blog, I had looked up Myriad Genesight and I was very surprised there was no price. On further review, I discovered there are multiple entries for Genesight with slightly different names, in both Ohio and Utah, some priced, and some not.
Part of a larger pattern?
I've heard that several different MACs have been posting their Category III code prices, which in the past they generally didn't do. (This recently resulted in a famous headache for iRhythm - see article.) Possibly CMS has encouraged MACs to post internal non-fee-schedule prices, when available. I know that Noridian, among others, has always listed internally-set prices as being available to the public, by FOIA upon request.
Quirks
Based on work I've done in the past, and based on Noridian FOIA requests, there were about 1000 MolDx locally-priced codes. All other tests were either (A) at fee schedule codes and prices, or (B) not covered and thus not priced.
Regarding price, the results of the DEX search can still be cryptic. For example, the Advanced Genetics lab in Connecticut has a "AGL Cardiology" pharmacogenetics panel test that is listed as "Covered" and "See Fee Schedule," but one has no idea how it is coded, so, you can't actually look to a fee schedule anywhere to find the payment.
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Some other little mysteries, puzzles, or items of interest.
- The Foundation Medicine liquid biopsy test is listed in italics, and it's not clear what this means.
- Some tests like FMI HEME test, are carefully coded by MolDx as 81479, unlisted code, but carefully priced at exactly the fee schedule price to the penny (for 81455 (50+ tumor genes)) typically used by other insurers and MACs.
- The CARIS BRCA test is listed as covered at $2380, although the more common coding would be 81162 for about $1800.
- I've seen tests listed as NOT COVERED in MolDx DEX, while the same lab directly was told their diagnostic test was out of scope of review by MolDx. This seems like a Catch-22?
