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Cap.org v. # College of American Pathologists Clinical Laboratory Fee Schedule Recommendations Michael D. McEachin, MD, CPT Advisor AMA-CPT Advisory Committee.

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Presentation on theme: "Cap.org v. # College of American Pathologists Clinical Laboratory Fee Schedule Recommendations Michael D. McEachin, MD, CPT Advisor AMA-CPT Advisory Committee."— Presentation transcript:

1 cap.org v. # College of American Pathologists Clinical Laboratory Fee Schedule Recommendations Michael D. McEachin, MD, CPT Advisor AMA-CPT Advisory Committee July 10, 2013

2 New 2014 CodeDescriptor Gap fill or Crosswalk If crosswalk, then to what existing code? Rationale Therapeutic Drug Assays 801XX1CaffeineCrosswalk 82491 Chromatography, quantitative, column (eg, gas liquid or HPLC); single analyte not elsewhere specified, single stationary and mobile phase Current Medicare National Limit Amount: $24.82. CPT code 801XX1 Caffeine was created for the Therapeutic drug Assays subsection of CPT through the efforts of the AMA-CPT Quantitative Drug Testing Workgroup to report quantitative assessment of Caffeine. Crosswalk to CPT code 82491 Chromatography, quantitative, column (eg, gas liquid or HPLC); single analyte not elsewhere specified, single stationary and mobile phase is recommended as a comparable quantitative methodology is used. 801XX Clozapine Crosswalk 80154 Benzodiazepines Current Medicare National Limit Amount: $25.43. CPT code 801XX2 Clozapine was created for the Therapeutic drug Assays subsection of CPT through the efforts of the AMA-CPT Quantitative Drug Testing Workgroup to report quantitative assessment of Clozapine. Crosswalk to CPT code 80154 Benzodiazepines is recommended as comparable quantitative methodology is used. © 2013 College of American Pathologists. All rights reserved. 2

3 New 2014 Code Descriptor Gap fill or Crosswalk If crosswalk, then to what existing code? Rationale Therapeutic Drug Assays 801XX3EverolimusCrosswalk 82542 Column chromatography/mass spectrometry (eg, GC/MS, or HPLC/MS), analyte not elsewhere specified; quantitative, single stationary and mobile phase Current Medicare National Limit Amount: $24.82. CPT code 801XX3 Everolimus was created for the Therapeutic Drug Assays subsection of CPT through the efforts of the AMA-CPT Quantitative Drug Testing Workgroup to report quantitative assessment of Everolimus. Crosswalk to CPT code 82542 Column chromatography/mass spectrometry (eg, GC/MS, or HPLC/MS), analyte not elsewhere specified; quantitative, single stationary and mobile phase is recommended as comparable quantitative methodology is used. 801XX4GabapentinCrosswalk 82491 Chromatography, quantitative, column (eg, gas liquid or HPLC); single analyte not elsewhere specified, single stationary and mobile phase Current Medicare National Limit Amount: $24.82. CPT code 801XX4 Gabapentin was created for the Therapeutic Drug Assays subsection of CPT through the efforts of the AMA-CPT Quantitative Drug Testing Workgroup to report quantitative assessment of Gabapentin. Crosswalk to CPT code 82491 Chromatography, quantitative, column (eg, gas liquid or HPLC); single analyte not elsewhere specified, single stationary and mobile phase is recommended as comparable quantitative methodology is used. © 2013 College of American Pathologists. All rights reserved. 3

4 New 2014 Code Descriptor Gap fill or Crosswalk If crosswalk, then to what existing code? Rationale Therapeutic Drug Assays 801XX5LamotrigineCrosswalk 82542 Column chromatography/mass spectrometry (eg, GC/MS, or HPLC/MS), analyte not elsewhere specified; quantitative, single stationary and mobile phase Current Medicare National Limit Amount: $24.82. CPT code 801XX5 Lamotrigine was created for the Therapeutic Drug Assays subsection of CPT through the efforts of the AMA-CPT Quantitative Drug Testing Workgroup to report quantitative assessment of Lamotrigine. Crosswalk to 82542 Column chromatography/mass spectrometry (eg, GC/MS, or HPLC/MS), analyte not elsewhere specified; quantitative, single stationary and mobile phase is recommended as comparable quantitative methodology is used. 801XX6LevetiracetamCrosswalk 82542 Column chromatography/mass spectrometry (eg, GC/MS, or HPLC/MS), analyte not elsewhere specified; quantitative, single stationary and mobile phase Current Medicare National Limit Amount: $24.82. CPT code 801XX6 Levetiracetam was created for the Therapeutic Drug Assays subsection of CPT through the efforts of the AMA-CPT Quantitative Drug Testing Workgroup to report quantitative assessment of Levetiracetam. Crosswalk to 82542 Column chromatography/mass spectrometry (eg, GC/MS, or HPLC/MS), analyte not elsewhere specified; quantitative, single stationary and mobile phase is recommended as comparable quantitative methodology is used. © 2013 College of American Pathologists. All rights reserved. 4

5 New 2014 CodeDescriptor Gap fill or Crosswalk If crosswalk, then to what existing code? Rationale Therapeutic Drug Assays 801XX7 Mycophenolate (mycophenolic acid) Crosswalk 82542 Column chromatography/mass spectrometry (eg, GC/MS, or HPLC/MS), analyte not elsewhere specified; quantitative, single stationary and mobile phase Current Medicare National Limit Amount: $24.82. CPT code 801XX7 Mycophenolate was created for the Therapeutic Drug Assays subsection of CPT through the efforts of the AMA-CPT Quantitative Drug Testing Workgroup to report quantitative assessment of Mycophenolate. Crosswalk to CPT code 82542 Column chromatography/mass spectrometry (eg, GC/MS, or HPLC/MS), analyte not elsewhere specified; quantitative, single stationary and mobile phase is recommended as comparable quantitative methodology is used. 801XX8OxcabazepineCrosswalk 82542 Column chromatography/mass spectrometry (eg, GC/MS, or HPLC/MS), analyte not elsewhere specified; quantitative, single stationary and mobile phase Current Medicare National Limit Amount: $24.82. CPT code 801XX8 Oxcarbazepine was created for the Therapeutic Drug Assays subsection of CPT through the efforts of the AMA-CPT Quantitative Drug Testing Workgroup to report quantitative assessment of Oxcarbazepine. Crosswalk to CPT code 82542 Column chromatography/mass spectrometry (eg, GC/MS, or HPLC/MS), analyte not elsewhere specified; quantitative, single stationary and mobile phase is recommended as comparable quantitative methodology is used. © 2013 College of American Pathologists. All rights reserved. 5

6 New 2014 CodeDescriptor Gap fill or Crosswalk If crosswalk, then to what existing code? Rationale Therapeutic Drug Assays 801XX9TiagabineCrosswalk 82542 Column chromatography/mass spectrometry (eg, GC/MS, or HPLC/MS), analyte not elsewhere specified; quantitative, single stationary and mobile phase Current Medicare National Limit Amount: $24.82. CPT code 801XX9 Tiagabine was created for the Therapeutic Drug Assays subsection of CPT through the efforts of the AMA-CPT Quantitative Drug Testing Workgroup to report quantitative assessment of Tiagabine. Crosswalk to CPT code 82542 Column chromatography/mass spectrometry (eg, GC/MS, or HPLC/MS), analyte not elsewhere specified; quantitative, single stationary and mobile phase is recommended as comparable quantitative methodology is used. 802XXZonisamideCrosswalk CPT 82542 Column chromatography/mass spectrometry (eg, GC/MS, or HPLC/MS), analyte not elsewhere specified; quantitative, single stationary and mobile phase Current Medicare National Limit Amount: $24.82. CPT code 802XX Zonisamide was created for the Therapeutic Drug Assays subsection of CPTthrough the efforts of the AMA-CPT Quantitative Drug Testing Workgroup to report quantitative assessment of Zonisamide. Crosswalk to CPT code 82542 Column chromatography/mass spectrometry (eg, GC/MS, or HPLC/MS), analyte not elsewhere specified; quantitative, single stationary and mobile phase is recommended as comparable quantitative methodology is used. © 2013 College of American Pathologists. All rights reserved. 6

7 New 2014 CodeDescriptor Gap fill or Crosswalk If crosswalk, then to what existing code? Rationale Molecular Pathology Tier 1 Molecular Pathology Procedures 81161 DMD (dystrophin) (eg, Duchenne/Becker muscular dystrophy) deletion analysis, and duplication analysis, if performed Crosswalk 81407 Molecular pathology procedure, Level 8 (eg, analysis of 26-50 exons by DNA sequence analysis, mutation scanning or duplication/deletion variants of >50 exons, sequence analysis of multiple genes on one platform) There is no current Medicare National Limit amount at this time. CAP supported physician schedule placement for this code and still does. As part of the RUC process, CPT code 81161 was recognized as equivalent in practice expense and physician work to Tier 2 code 81407 Level 8 Molecular pathology procedure, Level 8 (eg, analysis of 26-50 exons by DNA sequence analysis, mutation scanning or duplication/deletion variants of >50 exons, sequence analysis of multiple genes on one platform). Considering its current placement on the CLFS, CAP recommends the technical aspects of 81161 be crosswalked to 81407. © 2013 College of American Pathologists. All rights reserved. 7

8 New 2014 CodeDescriptor Gap fill or Crosswalk If crosswalk, then to what existing code? Rationale Molecular Pathology Tier 1 Molecular Pathology Procedures 812XX MGMT (O6- methylguanine DNA methyltransferase) (eg, Brain Cancer) allele specific identification of dense promoter methylation, analysis of the MGMT gene, prognostic/predictive for response for treatment which include alkylating agents such as temozolamide therapy in tumor tissue Crosswalk 81401 Molecular pathology procedure, Level 2 (eg, 2-10 SNPs, 1 methylated variant, or 1 somatic variant [typically using nonsequencing target variant analysis], or detection of a dynamic mutation disorder/triplet repeat) There is no current Medicare National Limit amount at this time. New code 812XX MGMT was created to allow more specific reporting of MGMT (O6- methylguanine DNA methyltransferase) (eg, Brain Cancer) allele specific identification of dense promoter methylation, analysis of the MGMT gene, prognostic/predictive for response for treatment which include alkylating agents such as temozolamide therapy in tumor tissue. CAP recommends the technical aspects of 812XX be crosswalked to 81401 as similar technical resources are required. © 2013 College of American Pathologists. All rights reserved. 8

9 New 2014 CodeDescriptor Gap fill or Crosswal k If crosswalk, then to what existing code? Rationale Multianalyte Assays with Algorithmic Analyses (Category I) 81508 Fetal congenital abnormalities, biochemical assays of two proteins (PAPP- A, hCG [any form]), utilizing maternal serum, algorithm reported as a risk score Crosswalk 84702 Gonadotropin, chorionic (hCG); quantitative ) with a CLFS NLA of $20.70 plus 84163 Pregnancy-associated plasma protein-A (PAPP-A) with a CLFS NLA of $20.70 Current Medicare National Limit Amount: $20.70 + $20.70 = $41.40 Code 81508 Fetal congenital abnormalities, biochemical assays of two proteins (PAPP-A, hCG [any form]), utilizing maternal serum, algorithm reported as a risk score was established for CPT 2013 within the new subsection of CPT for Multianalyte Assays with Algorithmic Analyses (MAAAs) for procedures that utilize multiple results derived from assays of various types. Algorithmic analysis using the results of these assays as well as other patient information (if used) is the performed and reported typically as a numeric score(s) or as a probability. A crosswalk to 84702 Gonadotropin, chorionic (hCG); quantitative with a CLFS NLA of $20.70 plus 84163 Pregnancy-associated plasma protein-A (PAPP-A) with a CLFS NLA of $20.70 is recommended as similar clinical resources are used to generate laboratory results for each analyte. If there is an additional cost associated with the generation/maintenance of the algorithm for new MAAA code 81508, it should be recognized as well. © 2013 College of American Pathologists. All rights reserved. 9

10 New 2014 Code Descriptor Gap fill or Crosswalk If crosswalk, then to what existing code? Rationale Multianalyte Assays with Algorithmic Analyses (Category I) 815XX1 Oncology (tissue of origin), microarray gene expression profiling of > 2000 genes, utilizing formalin-fixed paraffin embedded tissue, algorithm reported as tissue similarity scores N/A No comment at this time 815XX3 Fetal aneuploidy (trisomy 21, 18, and 13) DNA sequence analysis of selected regions using maternal plasma, algorithm reported as a risk score for each trisomy N/A No comment at this time. © 2013 College of American Pathologists. All rights reserved. 10

11 New 2014 Code Descriptor Gap fill or Crosswalk If crosswalk, then to what existing code? Rationale Microbiology 876XX Infectious agent detection by nucleic acid (DNA or RNA); Trichomonas vaginalis, amplified probe technique Crosswalk 87511 Infectious agent detection by nucleic acid (DNA or RNA); Gardnerella vaginalis, amplified probe technique Current Medicare National Limit Amount: $48.24 New code 876XX was established to report Infectious agent detection by nucleic acid (DNA or RNA); Trichomonas vaginalis, amplified probe technique. A crosswalk to 87511 is recommended as a similar amplified probe technique is used. © 2013 College of American Pathologists. All rights reserved. 11

12 Other CodesDescriptor Gap fill or Crosswalk If crosswalk, then to what existing code? Rationale Reconsideration Requests 0001M Infectious disease, HCV, six biochemical assays (ALT, A2- macroglobulin, apolipoprotein A-1, total bilirubin, GGT, and haptoglobin) utilizing serum, prognostic algorithm reported as scores for fibrosis and necroinflammatory activity in liver No additional comment at this time NA No additional comment at this time 0002M Liver disease, ten biochemical assays (ALT, A2-macroglobulin, apolipoprotein A-1, total bilirubin, GGT, haptoglobin, AST, glucose, total cholesterol and triglycerides) utilizing serum, prognostic algorithm reported as quantitative scores for fibrosis, steatosis and alcoholic steatohepatitis (ASH) No additional comment at this time NA No additional comment at this time © 2013 College of American Pathologists. All rights reserved. 12

13 Other CodesDescriptor Gap fill or Crosswalk If crosswalk, then to what existing code? Rationale Reconsideration Requests 0003M Liver disease, ten biochemical assays (ALT, A2-macroglobulin, apolipoprotein A-1, total bilirubin, GGT, haptoglobin, AST, glucose, total cholesterol and triglycerides) utilizing serum, prognostic algorithm reported as quantitative scores for fibrosis, steatosis and nonalcoholic steatohepatitis (NASH) No additional comment at this time NA No additional comment at this time 81500 Oncology (ovarian), biochemical assays of two proteins (CA-125 and HE4), utilizing serum, with menopausal status, algorithm reported as a risk score No additional comment at this time NA No additional comment at this time 81503 Oncology (ovarian), biochemical assays of five proteins (CA-125, apoliproprotein A1, beta-2 microglobulin, transferrin, and pre-albumin), utilizing serum, algorithm reported as a risk score No additional comment at this time NA No additional comment at this time © 2013 College of American Pathologists. All rights reserved. 13

14 Other CodesDescriptor Gap fill or Crosswalk If crosswalk, then to what existing code? Rationale Reconsideration Requests 81506 Endocrinology (type 2 diabetes), biochemical assays of seven analytes (glucose, HbAlc, insulin, hs-CRP, adoponectin, ferritin, interleukin 2- receptor alpha), utilizing serum or plasma, algorithm reporting a risk score No additional comment at this time NA No additional comment at this time 81509 Fetal congenital abnormalities, biochemical assays of three proteins (PAPP-A, hCG [any form], DIA), utilizing maternal serum, algorithm reported as a risk score No additional comment at this time NA No additional comment at this time 81510 Fetal congenital abnormalities, biochemical assays of three analytes (AFP, uE3, hCG [any form]), utilizing maternal serum, algorithm reported as a risk score No additional comment at this time NA No additional comment at this time 81511 Fetal congenital abnormalities, biochemical assays of four analytes (AFP, uE3, hCG [any form], DIA) utilizing maternal serum, algorithm reported as a risk score (may include additional results from previous biochemical testing) No additional comment at this time NA No additional comment at this time © 2013 College of American Pathologists. All rights reserved. 14

15 Other CodesDescriptor Gap fill or Crosswalk If crosswalk, then to what existing code? Rationale Reconsideration Requests 81512 Fetal congenital abnormalities, biochemical assays of five analytes (AFP, uE3, total hCG, hyperglycosylated hCG, DIA) utilizing maternal serum, algorithm reported as a risk score No additional comment at this time NA No additional comment at this time 82777Galectin-3 No additional comment at this time NA No additional comment at this time © 2013 College of American Pathologists. All rights reserved. 15

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