Health Information Management

Tip: Note payment variations for molecular pathology codes

APCs Insider, July 19, 2013

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In some cases, payment for molecular pathology tests varies widely from one MAC to another. 

Consider CPT® code 81226 (cytochrome p450 genotyping). First Coast, the MAC for Florida, Puerto Rico, and the U.S. Virgin Islands lists payment for CPT code 81226 as $505.76. Cahaba, the MAC for Alabama, Georgia, and Tennessee will pay only $50 for the same test. The payment rates for the codes 81280, 81281, and 81282 for long QT syndrome gene analyses are also dramatically different.

Cahaba lists payment for each of those codes at only $123. In contrast, First Coast has code 81280 reimbursing at $3,140.90, code 81281 at $3,888.71, and code 81828 at $8,792.88. First Coast and Cahaba are the only two MACs that list reimbursement rates for these codes.

First Coast is paying a different amount for each test, while Cahaba is paying the same amount for all three. That could be another point for providers to consider. Do all three tests really cost the same amount to perform? Why do the payment rates vary so dramatically?

Not all of the differences are this dramatic, but even a $10 or $15 difference could mean that labs in one MAC jurisdiction receive enough payment to cover the costs of performing the test while those in another jurisdiction do not.

CMS is currently reviewing provider comments about the payment rates for molecular pathology laboratory tests. The agency plans to post the final gapfill payments on its website in September. CMS will use those prices to pay for molecular pathology testing in 2013 and 2014. Providers will have 30 days to comment on those final rates.

This tip is adapted from “CMS seeks provider comments on molecular pathology rates” in the July issue of Briefings on APCs.



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