Reimbursement in molecular pathology: bringing genomic medicine to patients.

Abstract

In 2008, the Association for Molecular Pathology (AMP)2 Economic Affairs Committee (EAC), under the leadership of the late Dr. Jeffrey Kant, embarked on a project to design new Current Procedural Terminology (CPT) codes for identification and billing of molecular pathology services. At that time, payers were confronted with a dizzying array of highly technical method-based CPT codes that described the various steps used in performing molecular assays. Examples included “83890 isolation or extraction, each nucleic acid type (i.e., DNA or RNA)”; “83898 amplification, target, each nucleic acid sequence”; “83904 mutation identification by sequencing, single segment, each segment”; and “83912 interpretation and report.” Laboratories “stacked” these codes on claim forms along with numerals that specified the number of times each step was performed. Payers could only guess at what the particular test was or why it was performed. Use of the CPT stacking codes was not uniform, and there was no way to ensure that tests were properly coded. Moreover, if more than one test was performed on a sample, Medicare Administrative Contractors (MACs) were unable to allocate CPT codes between tests. Finally, this coding structure left open the possibility that reimbursement rates for individual steps could influence assay design. Despite their shortcomings, the stacking codes had a powerful redeeming feature. Molecular pathology was characterized by both rapid growth and continual technological change. The stacking code format offered great flexibility and an ability to readily accommodate new tests and assay designs, benefitting patients and helping to advance the field. The AMP EAC's efforts culminated in production of a whitepaper that proposed an innovative approach to coding molecular pathology procedures in genetics, oncology, and histocompatibility. This document was submitted to the American Medical Association (AMA) CPT Editorial Panel for consideration (1). In response, the AMA convened a workgroup “to propose solutions …