The Centers for Medicare and Medicaid Services (CMS) finalized pricing for new, analyte-specific molecular codes in late September. Compared to the former stacked code system, which did not list prices for individual tests, the average price of the new codes is 26% higher and the mean price is 25% higher. However, the median price declined 15%. In addition, out of the 116 new codes, pricing was only specified for 65 codes. Local Medicare contractors are being allowed to issue lower prices for certain codes. Some tests, largely pharmacogenetic tests, are being denied coverage, which observers attribute to the lack of peer-reviewed published evidence of their clinical utility. Labs, especially independent labs, are expected to face additional pricing challenges due to new CMS rules. A proposed rule for the outpatient prospective payment system would base lab service reimbursements on the ambulatory payment classification. Another proposed change, affecting the physician fee schedule, would lower anatomic pathology payments by capping certain rates.

Source: Clinical Laboratory News