Economic Affairs Committee Report
By Jeffrey A. Kant MD, PhD
Chair, Economic Affairs Committee
The Economic Affairs Committee (EAC) continues to participate in discussions within the AMA CPT Molecular Pathology Workgroup to create a new system for coding molecular tests in oncology and genetics as discussed in detail in the June 2011 Newsletter. The new codes will be published in the 2012 CPT book - although this does not mean they will be used widely yet. That is because CMS, which will decide whether (and which) CPT codes go on the Clinical Laboratory Fee Schedule (CLFS) and/or Physician Fee Schedules (PFS), decided it needed more time to study fee schedule placement of these codes and did not include any new codes for discussion at the July 2011 code valuation meeting for the CLFS. This decision effectively places the new codes in limbo until July 2012 with earliest utilization (by Medicare) in January 2013. However, there is still a chance some (unlikely all) of the new CPT codes which describe services performed primarily by physicians may be placed on the Physician Fee Schedule by CMS to take effect January 2012. With this in mind, the AMA RUC (which values professional work and practice expense for codes on the PFS) surveyed a substantial number of the new codes in August. Many thanks to those physicians who filled out these surveys. What private insurance companies will do with accepting and paying for the new molecular CPT codes is unknown.
Note: EAC will host a presentation 10:15 AM to 11:45 AM, Friday, November 18, 2011 at the AMP Annual Meeting to describe the CPT code development and valuation process; yours truly will moderate with Roger Klein and Vicky Pratt participating. There will be ample time for audience questions.
The delay by CMS in deciding fee schedule placement ups the urgency around efforts to obtain legislative recognition for non-physician doctoral scientists with appropriate molecular training to bill professional component services on the PFS. The field is currently in a Catch-22 situation where tests performed primarily by non-physician providers may not be considered for the PFS, no matter how complex the interpretive work involved, because CMS is not currently permitted to recognize non-physician doctoral scientists. The likelihood of Congressional action in 2011 on this initiative is remote, so we are preparing legislative language and financial "scoring" this Fall for a "push" early next year before CMS makes decisions on fee schedule placement. While there are some differences of opinion, a majority of those speaking at a special meeting hosted by CMS on fee schedule placement, favored putting most or all new molecular codes on the PFS.
In late September EAC held a day-long discussion to begin exploration of whether it is possible to reconcile concepts (e.g. value-based reimbursement, recoupment of developmental costs, standards of evidence supporting testing) that often separate academic and commercial laboratories. The hope was to seek win-win propositions and produce a whitepaper outlining a balanced perspective of issues in these areas with a goal of attracting further healthcare dollars to diagnostics including personalized medicine.