Gapfill Pricing Inquiries
Notification of Reconsideration Period –
2013 Gapfill Payment Amounts
Clinical Laboratory Fee Schedule (CLFS)
For Calendar Year (CY) 2013, CMS is using the gapfilling methodology to establish payment rates for Molecular Pathology Current Procedural Terminology (CPT) codes being paid using the Clinical Laboratory Fee Schedule.
The gapfilling process requires the Medicare Administrative Contractors (MACs) to set payment rates using a broad range of information outlined in CMS’ Code of Federal Regulations (CFR) at 42 CFR 414.508(b).
MACs forwarded their interim contractor-specific payment amounts to CMS earlier this year, and CMS posted that information on our web site on May 9, 2013 at http://www.cms.hhs.gov/ClinicalLabFeeSched.
As outlined at 42 CFR 414.509(b)(2), the public had 60 days from the date of this web posting to comment to CMS about this information. CMS appreciates the comments that it received. Each comment was shared with the MACs and carefully considered in regards to the gapfilling decision.
CMS is now posting revised gapfill prices including the 2014 National Limit Amount (NLA). Only those codes that are currently being paid by the MACs are listed. Some codes listed in the May 9, 2013 posting are not currently shown because the service is no longer being paid by the MAC. The inclusion of a code and/or payment amount for a particular clinical diagnostic laboratory test does not imply that the test will be covered under the Medicare program.
The public will have 30 days to request reconsideration of the NLAs listed in the September web posting. In order to be considered by CMS, reconsideration requests must be received by CMS by October 30, 2013. Send all reconsideration requests directly to CMS at MoPathGapfillInquiries@cms.hhs.gov. You may copy your MAC on your comment to CMS; however, please do not comment directly to your MAC without including CMS on your submission.
Please provide the following specific information about your test if you wish it be considered for reconsideration:
- Test Methodology (e.g., Real-time Quantitative PCR (RQ-PCR), Reverse-transcription PCR (RT-PCR), flow cytometry, capillary electrophoresis, fragment analysis etc)
- Specific cost per sample (specify reagent, direct labor costs, equipment costs, indirect costs, etc)
If CMS revises any NLA as a result of the reconsideration process, the revised NLA will be the upper limit on payment beginning 1/1/2014. Once the reconsideration process is completed for this gapfill process, the determination is final and will not be subject to further reconsideration. MACs will continue to determine pricing for the remainder of 2013.
If you have any questions regarding the comment process, please contact CMS via e-mail, at the above address. Thank you in advance for providing thoughtful informative input to us about these important decisions.
- Page last Modified: 10/18/2013 9:59 AM
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