Monday, October 26, 2015
Posted by: Rebecca Riedesel
ASHI is pleased to provide this CPT informational page for the convenience and education of the HLA community. Please be aware that sometimes the links may have vendor or third party associations which ASHI neither supports nor promotes. Registration may be required for access to related articles. ASHI is not responsible for emails received from the vendor or third party.
December 2012 Information
CMS published the final rule in November. You can find the complete ruling at here. Discussion of molecular pathology codes starts on page 104.
In short, CMS determined that all molecular CPT codes, including HLA, will be paid on the Clinical Laboratory Fee Schedule using the gapfill method. Physicians will be able to use a HCPCS code to provide a medical narrative interpretation over and above the interpretation of the data required to provide a result. PhDs will not be allowed to use this code.
Here is a summary from the American Society for Hematology.
Payment for Molecular Pathology Services:
In the proposed rule, CMS invited comments on whether newly created molecular pathology CPT codes should be paid under the PFS or the Clinical Laboratory Fee Schedule (CLFS). CMS decided to include the molecular pathology CPT codes under the CLFS because the services do not ordinarily require interpretation by a physician to produce a meaningful result. CMS accepted the argument that non-physician geneticists can provide the necessary interpretation for a meaningful test result of a molecular pathology test if some interpretation is required and that physician interpretation currently is not typical across molecular pathology services.
CMS stated that they recognize there may be situations where a physician interpretation of a molecular pathology test might be needed and they established a new HCPCS code G0452 (molecular pathology procedure; physician interpretation and report) to describe medically necessary interpretation and written report of a molecular pathology test, above and beyond the report of laboratory results. This professional component-only HCPCS G-code will be considered a "clinical laboratory interpretation service." CMS assigned a total of 0.55 RVUs to G0452, which converts to a payment of about $18.70. Under existing rules for payment of clinical laboratory interpretation services, the interpretation (1) must be requested by the patient’s attending physician, (2) must result in a written narrative report included in the patient’s medical record, and (3) requires the exercise of medical judgment by the consultant physician. A hospital’s standing order policy can be used as a substitute for the individual request by a patient’s attending physician.”
As of January 1, 2013, the CPT stacking codes for molecular testing will be removed from the list of CPT codes. All payors including Medicare will accept these codes. The complete list of all of the new CPT codes, effective January 1, 2013, can be found in the recently published AMA CPT Codebook. Changes to codes of interest to HLA labs are the new solid phase antibody codes in the tissue typing section and the molecular HLA and chimerism codes in the molecular section. The molecular codes were published in 2012, but will be fully implemented in 2013. The antibody codes are new for 2013. To obtain a copy of the AMA CPT codebook, click here.
November 2012 Information
The seven-member coalition of laboratory professional associations (including ASHI, CAP, NAME, AMP, ACMG, ACLA and ASCP) has visited the House Ways and Means and Senate Finance Committee members to seek sponsors for legislation to designate non-physician doctoral scientists with appropriate training and experience as Qualified Health Care Practitioners. As such they would be permitted to bill Medicare directly from the Physician Fee Schedule for interpretive services for tests in the Molecular Pathology section of the CPT® codebook. Committee staffers are very interested in the issue and open to supporting the legislation but so far no primary sponsors have emerged.
September 2012 Information
The CMS preliminary payment determinations for new tests for 2013 can be found at the link below. This includes the new codes for antibody to HLA and also information on the molecular codes. CMS accepted ASHI’s payment recommendations for the antibody codes (click here to view). They are still deliberating on the placement of the molecular codes (Clinical Lab Fee Schedule vs Physician’s Fee Schedule). If they go on the CLFS, payment will be determined by the gapfill process. Comments will be accepted by CMS until September 2012. The final payment determinations will be posted in November and will go into effect in January.Click here for more information.
July 2012 Information
The new AMA-CPT codes which will be on the Clinical Lab Fee Schedule for 2013 are now posted on the CMS website. The 2013 codes include new Tissue Typing codes for solid phase antibody testing. This list also includes the molecular codes that went into effect in 2012, but for which Medicare has delayed making payment policy. There is still no final decision as to whether they will be paid from the Physician’s Fee Schedule or the Clinical Lab Fee Schedule.
The complete list can be found at: http://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/ClinicalLabFeeSched/Downloads/CY2013-Public-Meeting-New-Test-Codes-aeth.pdf
CMS will hold a Public Meeting for the Laboratory Payment for New Clinical Test Codes for 2013 on Monday, July 16 and Tuesday, July 17, 2012 at the Centers for Medicare & Medicaid Services Auditorium in Baltimore, MD. At that meeting they will also take comments on the payment policy for the molecular codes. The initial notice was published in the May 29 Federal Register. The link for that notice is: http://www.gpo.gov/fdsys/pkg/FR-2012-05-29/pdf/2012-12982.pdf
ASHI will have representation at the meeting and will present payment recommendations. There will be a call-in number for listening only. A limited number of lines will be available on a first come, first served basis. If interested, use the call-in number below to listen to the meeting:
Conference Call Number: 1-877-267-1577
Meeting ID: 6035
February 2012 Information
The CPT codes discussed at the February CPT meeting and the action taken by the CPT panel are posted on the AMA website at
The actual codes will be published in CPT 2013 and will become effective January 1, 2013. The text of the codes is confidential and cannot be distributed.
Per the AMA :
Please be aware that these actions are a reflection of the discussions at the most recent Panel meeting. Future Panel actions may impact these items. Codes are not assigned, nor exact wording finalized, until just prior to publication. Release of this more specific CPT ®code set information is timed with the release of the entire set of coding changes in the CPT publication.
Presentation from the Pathology and Laboratory representative to the AMA CPT panel at the CPT® and RBRVS 2013 Annual Symposium. There is general information as well as specific information regarding the HLA molecular codes.
History of the Molecular pathology working group :
Update of MPWG activity from the Oct 2011 CPT meeting
Update of MPWG activityfrom the Feb 2012 CPT meeting. (not much HLA, but process for adding new molecular codes like KIR is discussed.)
January 2012 Information
December 2011 Information
Medicare has provided some additional information about CPT coding for genetic tests in 2012. While they will only accept the current stacking codes for 2012, they are requesting that labs bill BOTH the stacking codes and the new CPT codes for genetic tests (including HLA and chimerism). They are requesting an estimated charge be attached to the new codes. They will not pay this charge, but they wish information for developing a charge structure. See links below to a CMS newsletter and also an article about this request. In addition, a link is provided for the CMS Clinical lab fee schedule for 2012, for your information.
https://www.cms.gov/MLNMattersArticles/downloads/MM7654.pdf (pages 3-4)