Home 5 Lab Industry Advisor 5 Essential 5 Medicare to Pay for 22 Additional PLA Codes, Starting April 1

Medicare to Pay for 22 Additional PLA Codes, Starting April 1

by | Mar 28, 2023 | Essential, Lab Compliance Advisor, Reimbursement-lca

To ensure proper Medicare Part B billing and coding, your billing staff must be aware of all 22 of the newly recognized PLA codes.

Every year, the Centers for Medicare & Medicaid Services (CMS) adds to the list of Proprietary Laboratory Analysis (PLA) codes reimbursable by Medicare Part B under the Clinical Laboratory Fee Schedule (CLFS). On Feb. 2, CMS issued its quarterly Medicare Learning Network transmittal (CR 13082), revealing the new PLA code additions for 2023.1 Among them are widely used oncology, infectious agent, and other assays produced by major lab companies like Thermo Fisher Scientific, DiaCarta, and Adaptive Biotechnologies. There’s a pretty good possibility that your lab provides at least some of these newly recognized PLA code tests to Medicare patients.

There’s a lot at stake. When a PLA code is available to report a given proprietary laboratory service, that same service shouldn’t be reported with any other Current Procedural Terminology (CPT) code(s) and other CPT code(s) shouldn’t be used to report services that may be reported with that specific PLA code.

Bottom Line: To ensure proper Medicare Part B billing and coding, your billing staff must be aware of all 22 of the newly recognized PLA codes that will become officially payable, starting on April 1, 2023.

PLA Codes 101

While most lab test products are manufactured by multiple companies, some assays are proprietary to and associated with a single company or lab. The American Medical Association (AMA) incorporated PLA codes into its CPT coding system to identify these tests. PLA codes are alphanumeric codes consisting of four digits and ending with the uppercase letter “U.” Each PLA code also includes a code descriptor. It’s up to each lab or manufacturer to decide whether it wants to have a PLA code assigned to identify its product.

The Protecting Access to Medicare Act (PAMA) defines four kinds of lab tests that should be assigned PLA codes, including:

  • Advanced diagnostic laboratory tests (ADLTs)
  • Clinical diagnostic laboratory tests (CDLTs) that are not ADLTs
  • Multianalyte assays with algorithmic analyses (MAAA)
  • Genomic sequencing procedures

PLA coded tests may be performed either by “one, sole source” lab or multiple labs to whom that lab licenses the test. When CMS first recognizes a PLA code test, it leaves it to the Medicare Administrative Contractors (MACs) to decide how much to reimburse for the test in their jurisdiction. Eventually, CMS sets a national price for each PLA test.

The Newly Recognized PLA Codes

Medicare will pay for 22 additional PLA tests, starting April 1, 2023:

New PLA Codes Added to CLFS, Effective April 1, 2023

Laboratory CPT Code Long Descriptor Short Descriptor
clonoSEQAssay, Adaptive Biotechnologies 0364U Oncology (hematolymphoid neoplasm), genomic sequence analysis using multiplex (PCR) and next-generation sequencing with algorithm, quantification of dominant clonal sequence(s), reported as presence or absence of minimal residual disease (MRD) with quantitation of disease burden, when appropriate ONC HL NEO GEN SEQ ALYS ALG
Oncuria Detect, DiaCarta Clinical Lab, DiaCarta, Inc 0365U Oncology (bladder), analysis of 10 protein biomarkers (A1AT, ANG, APOE, CA9, IL8, MMP9, MMP10, PAI1, SDC1, and VEGFA) by immunoassays, urine, algorithm reported as probability of bladder cancer ONC BLDR 10 PRB BLDR CA
Oncuria Monitor, DiaCarta Clinical Lab, DiaCarta, Inc 0366U Oncology (bladder), analysis of 10 protein biomarkers (A1AT, ANG, APOE, CA9, IL8, MMP9, MMP10, PAI1, SDC1, and VEGFA) by immunoassays, urine, algorithm reported as probability of recurrent bladder cancer ONC BLDR 10 PRB RECR BLDR CA
Oncuria Predict, DiaCarta Clinical Lab, DiaCarta, Inc 0367U Oncology (bladder), analysis of 10 protein biomarkers (A1AT, ANG, APOE, CA9, IL8, MMP9, MMP10, PAI1, SDC1, and VEGFA) by immunoassays, urine, diagnostic algorithm reported as risk score for probability of rapid recurrence of recurrent or persistent cancer following transurethral resection ONC BLDR 10 FLWG TRURL RESCJ
 GI assay (Gastrointestinal Pathogen with ABR), Lab Genomics LLC, Thermo Fisher Scientific 0369U Infectious agent detection by nucleic acid (DNA and RNA), gastrointestinal pathogens, 31 bacterial, viral, and parasitic organisms and identification of 21 associated antibiotic-resistance genes, multiplex amplified probe technique IADNA GI PTHGN 31 ORG&21 ARG
Lesion Infection (Wound), Lab Genomics LLC, Thermo Fisher Scientific 0370U Infectious agent detection by nucleic acid (DNA and RNA), surgical wound pathogens, 34 microorganisms and identification of 21 associated antibiotic-resistance genes, multiplex amplified probe technique, wound swab IADNA SURG WND PTHGN 34&21
Qlear UTI, Lifescan Labs of Illinois, Thermo Fisher Scientific 0371U Infectious agent detection by nucleic acid (DNA or RNA), genitourinary pathogen, semiquantitative identification, DNA from 16 bacterial organisms and 1 fungal organism, multiplex amplified probe technique via quantitative polymerase chain reaction (qPCR), urine IADNA GU PTHGN SEMIQ DNA16&1
Qlear UTI – Reflex ABR, Lifescan Labs of Illinois, Thermo Fisher Scientific 0372U Infectious disease (genitourinary pathogens), antibiotic-resistance gene detection, multiplex amplified probe technique, urine, reported as an antimicrobial stewardship risk score NFCT DS GU PTHGN ARG DETCJ
Respiratory Pathogen with ABR (RPX), Lab Genomics LLC, Thermo Fisher Scientific 0373U Infectious agent detection by nucleic acid (DNA and RNA), respiratory tract infection, 17 bacteria, 8 fungus, 13 virus, and 16 antibiotic-resistance genes, multiplex amplified probe technique, upper or lower respiratory specimen IADNA RSP TR NFCT 17 8 13&16
Urogenital Pathogen with Rx Panel (UPX), Lab Genomics LLC, Thermo Fisher Scientific 0374U Infectious agent detection by nucleic acid (DNA or RNA), genitourinary pathogens, identification of 21 bacterial and fungal organisms and identification of 21 associated antibiotic-resistance genes, multiplex amplified probe technique, urine IADNA GU PTHGN 21 ORG&21ARG
 OvaWatchSM, Aspira Women’s HealthSM, Aspira Labs, Inc 0375U Oncology (ovarian), biochemical assays of 7 proteins (follicle stimulating hormone, human epididymis protein 4, apolipoprotein A-1, transferrin, beta-2 macroglobulin, prealbumin [i.e., transthyretin], and cancer antigen 125), algorithm reported as ovarian cancer risk score ONC OVRN BCHM ASY 7 PRTN ALG
ArteraAI Prostate Test, Artera Inc 0376U Oncology (prostate cancer), image analysis of at least 128 histologic features and clinical factors, prognostic algorithm determining risk of distant metastases, and prostate cancer-specific mortality, includes predictive algorithm to androgen deprivation therapy response, if appropriate ONC PRST8 CA IMG ALYS 128
Liposcale, CIMA Sciences, LLC 0377U Cardiovascular disease, quantification of advanced serum or plasma lipoprotein profile, by nuclear magnetic resonance (NMR) spectrometry with report of a lipoprotein profile (including 23 variables) CV DS QUAN ADVSRM/PLSM LPRTN
UCGSL RFC1 Repeat Expansion Test, University of Chicago Genetic Services Laboratories 0378U RFC1 (replication factor C subunit 1), repeat expansion variant analysis by traditional and repeat-primed PCR, blood, saliva, or buccal swab RFC1 REPEAT XPNSJ VRNT ALYS
Solid Tumor Expanded Panel, Quest Diagnostics 0379U Targeted genomic sequence analysis panel, solid organ neoplasm, DNA (523 genes) and RNA (55 genes) by next generation sequencing, interrogation for sequence variants, gene copy number amplifications, gene rearrangements, microsatellite instability, and tumor mutational burden TGSAP SL OR NEO DNA523&RNA55
 PersonalisedRX, Lab Genomics LLC, Agena Bioscience, Inc 0380U Drug metabolism (adverse drug reactions and drug response), targeted sequence analysis, 20 gene variants and CYP2D6 deletion or duplication analysis with reported genotype and phenotype RX METB ADVRS TRGT SQ ALY 20
Branched-Chain Amino Acids, SelfCollect, Blood Spot, Mayo Clinic, Laboratory Developed Test 0381U Maple syrup urine disease monitoring by patient-collected blood card sample, quantitative measurement of alloisoleucine, leucine, isoleucine, and valine, liquid chromatography with tandem mass spectrometry (LC-MS/MS) MAPLE SYRUP UR DS MNTR QUAN
Phenylalanine and Tyrosine, SelfCollect, Blood Spot, Mayo Clinic, Laboratory Developed Test 0382U Hyperphenylalaninemia monitoring by patient-collected blood card sample, quantitative measurement of phenylalanine and tyrosine, liquid chromatography with tandem mass spectrometry (LC-MS/MS) HYPRPHENYLALNI NMIA MNTR QUAN
Tyrosinemia FollowUp Panel, SelfCollect, Blood Spot, Mayo Clinic, Laboratory Developed Test 0383U Tyrosinemia type I monitoring by patient-collected blood card sample, quantitative measurement of tyrosine, phenylalanine, methionine, succinylacetone, nitisinone, liquid chromatography with tandem mass spectrometry (LC-MS/MS) TYROSINEMIA TYP I MNTR QUAN
NaviDKDTM Predictive Diagnostic Screening for Kidney Health, Journey Biosciences, Inc, Journey Biosciences, Inc 0384U Nephrology (chronic kidney disease), carboxymethyllysine, methylglyoxal hydroimidazolone, and carboxyethyl lysine by liquid chromatography with tandem mass spectrometry (LC-MS/MS) and HbA1c and estimated glomerular filtration rate (GFR), with risk score reported for predictive progression to high-stage kidney disease NEPH CKD RSK HI STG KDN DS
PromarkerD, Sonic Reference Laboratory, Proteomics International Pty Ltd 0385U Nephrology (chronic kidney disease), apolipoprotein A4 (ApoA4), CD5 antigen-like (CD5L), and insulin-like growth factor binding protein 3 (IGFBP3) by enzyme-linked immunoassay (ELISA), plasma, algorithm combining results with HDL, estimated glomerular filtration rate (GFR) and clinical data reported as risk score for developing diabetic kidney disease NEPH CKD ALG RSK DBTC KDN DS
Envisage, Capsulomics, Inc 0386U Gastroenterology (Barrett’s esophagus), P16, RUNX3, HPP1, and FBN1 methylation analysis, prognostic and predictive algorithm reported as a risk score for progression to high-grade dysplasia or esophageal cancer GI BARRETT ESOPH MTHYLTN ALY
Source: Recreated from CMS Manual System, Pub 100-04 Medicare Claims Processing, Transmittal 11829.2 Download as a PDF.

Discontinued Codes

CMS also removed two discontinued Healthcare Common Procedure Coding System (HCPCS) codes from the CLFS:

·       0324U (Oncology (ovarian), spheroid cell culture, 4-drug panel (carboplatin, doxorubicin, gemcitabine, paclitaxel), tumor chemotherapy response prediction for each drug); and
·       0325U (Oncology (ovarian), spheroid cell culture, poly (ADPribose) polymerase (PARP) inhibitors (niraparib, olaparib, rucaparib, velparib), tumor response prediction for each drug.

 

Labs will want to make sure that their billing staff know about these discontinued HCPCS codes, as well as the 22 new PLA ones, in order to ensure proper billing and coding for reimbursement under Medicare Part B.

References:

  1. https://www.cms.gov/files/document/mm13082-clinical-laboratory-fee-schedule-laboratory-services-subject-reasonable-charge-payment.pdf
  2. https://www.cms.gov/files/document/r11829cp.pdf

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