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Billing & Coding: Pathology Group Asks CMS to Raise Medicare Prices for BRCA1/2 Sequencing Tests

The Association for Molecular Pathology (AMP) thinks the final 2019 Clinical Laboratory Fee Schedule payment amounts shortchanges labs that provide BRCA genetic testing and is calling on CMS to increase the payments.

The 2 CPT Codes at Issue

The tests in issue are CPT code 81163 for full sequencing of BRCA1 and BRCA2 genes and CPT code 81165 for sequencing of just BRCA1, for which the CLFS lists the payment amounts as, respectively, $468 and $283.

CPT 81163: AMP contends that the methodology CMS used to arrive at the payment amount for CPT 81163, i.e., crosswalking to code 81406 for BRCA1 sequencing and to code 81216 for BRCA2 sequencing, fails to account for all the work and costs labs incur in performing full sequencing of the two genes. Instead, AMP is asking the agency to crosswalk CPT 81163 to CPT 81408 for sequencing of large genes, which is paid at $2,000.

CPT 81165: In setting the payment amount for CPT 81165 full sequencing of BRCA1 at $283, CMS crosswalked to CPT 81406 covering sequencing analysis of 11 to 25 exons for genes such as RAF1 and ACADVL. But AMP argues that 81406 doesn’t account for all the work required to fully sequence BRCA1, a large and variable gene with 24 exons and over 7,000 base pairs, as compared to RAF1’s 3,300 and ACADVL’s 2,200 base pairs. So, AMP wants CMS to crosswalk to CPT 81408 and price it 50% less at $1,000 to more accurately cover the resources required.

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