CMS Publishes Annual Lab Meeting Code List, Adds Final Updates

UPDATE: FRIDAY, 5/26, CMS RELEASED THE EXPANDED AGENDA w/ MAY CODES.  

This adds codes from the May 2023 AMA CPT meeting.   This includes several for Acetylcholine receptor antibodies, a muscle-kinase antibody, and Hep D quantification.  Plus, 18 PLA codes, plus one Admin MAAA code (---M).

At CMS, you might have to refresh or reboot your browser to "see" the updated 5/26 file at the far bottom of the web page.

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The Lab Pricing Public Meeting

Every summer, CMS holds "Crosswalk/Gapfill" meetings to assist it in pricing new lab tests.  This year, the meeting is Thursday, June 22, 2023, public comments due June 1.  The meeting does not require registration and is streaming-only, unless you want to submit a public comment and register to speak.

April Agenda Versus Bigger, Last-Minute Agenda

For years, CMS publishes the test code agenda twice.  One version comes out around May 1, and includes codes passing AMA review through the first quarter.   Then a second version comes out, sometime circa June 1, which includes last minute codes finalized by AMA in early May.

The April Agenda Assessed

CMS issued the prelimary agenda on April 27.   I missed it because it is at the far-bottom of the relevant webpage.   Here's the link to the webpage, scroll to the far bottom, and see the 2024 code list.  (I'm giving the way page rather than a specific link, to allow for unpredictable CMS updates).

https://www.cms.gov/medicare/medicare-fee-for-service-payment/clinicallabfeesched/laboratory_public_meetings

At this web page, click on the meeting notice heading, and then ALSO when that opens, scroll to the far bottom. 

In this April 27 version, there are 64 items.

• RECONSIDERARTION OR REVISIONS
• Six PLA codes submitted for reconsideration.  Four are items 1-4 - 0326U, 0324U, 0348U, 0350U.  Later, items 39 and 41 are also reconsidered PLA codes (0329U, 0334U).
• One regular CPT code is also reconsidered, 87467, microbiology, HepB SAg, quantitative.
• Two PLA codes are on the agenda for "substantial revisions" which are 0022U and 0095U.
• NEW CODES
• NEW PLA codes run from 355U to 401U.   
• Again, we would normally expect CMS to add a couple dozen last minute PLA codes around June 1.
• There are 8 new Category I PLA codes.  
• 2 of them are not genomic.  8X016 is anti mullerian hormone chemistry, 8X025 is liver disease, 3 biomarkers, risk score.
• 6 of them are genomic sequencing procedures.   3 are for solid organ sequencing, 3 are for solid organ sequencing specifying liquid biopsy (cell free nucleic acid).

These six codes that revamp genomic tumor sequencing are a big deal and will have a lot of impact when active beginning in January 2024.

The three genomic codes (show in orange below) are three tiers of test functions.   The first is sequence variants, DNA analysis, microsatellite instability.   The second is sequence variants, DNA analysis, copy number variants and microsatellite instability.   The third is sequence variants, DNA analysis OR DNA/RNA analysis, vopy number variants, microsatellite instability, AND tumor mutation burden and rearrangements.   The three tiers of liquid biopsy codes have a similar but not identical pattern of added features row by row.

Click to enlarge.

AMA 2024 Copyright

The CMS April Agenda is the first chance to see the full code names for the new codes. Otherwise AMA CPT doesn't release them til around September 1.

Will There Be More Codes?

Consistently, year on year, CMS has added about 20  codes at the last minute (e.g. now) to the agenda.  That doesn't mean they must do so this year.  The 65-item agenda we today have "could" be the final agenda.

Appeals Cryptic

After last years crosswalk and "turf to gapfill" decisions were announced, labs had 60 days to request reconsideration.  This basically means the code appears on this summer's schedule again.   Labs are required to submit justification and rationale for reconsideration, but CMS doesn't publish that, so we are in the dark as to what exactly was in dispute for the 7 reconsidered codes.   

We do know this.  If the code is in crosswalk, the issue may be either a different crosswalk or turf-to-gapfill instead.   If the code is in gapfill, the only appeal is to request it be assigned some crosswalk.   Every year in January, the fee schedule expands, so it's possible a stakeholder may recommend a crosswalk in June 2023 that didn't exist the last time around in June 2022.