Reimbursement Position Statements

The Coalition for 21st Century Medicine’s Reimbursement Workgroup is playing a lead role in crafting the future of coding, coverage, and payment for advanced diagnostics. Over the past year the Coalition has engaged directly with the Centers for Medicare & Medicaid Services (CMS) on the implementation of the Protecting Access to Medicare Act of 2014 (PAMA). Section 216, entitled Improving Medicare Policies for Clinical Diagnostic Laboratory Tests, of PAMA modernizes the Medicare payment system for clinical laboratory tests with the establishment of a market-based payment system. This will be the most significant modernization of the Clinical Laboratory Fee Schedule (CLFS) since the introduction of the CLFS in 1984. Additionally, the Coalition has been actively engaged with other critical stakeholders such as the American Medical Association CPT Editorial Panel on coding policy, and with the Medicare Administrative Contractors (MAC) on coverage policy and evidentiary requirements.

Letter to Centers for Medicare & Medicaid Regarding Hospital Outpatient Prospective Payment System, Proposed Rule – Potential Changes to the Laboratory Date of Service Policy

On behalf of the Coalition for 21st Century Medicine, we appreciate the opportunity to comment on the Hospital Outpatient Prospective Payment System Proposed Rule for Calendar Year 2020. We are writing in strong support of maintaining the current laboratory date of service policy at 42 CFR 414.510(b)(5), which has dramatically improved beneficiary access to innovative molecular diagnostic tests to guide physicians in selecting appropriate care for complex diseases like cancer, cardiovascular disease, and rheumatoid arthritis.

Letter to CMS Regarding Revisions to the Laboratory Date of Service Policy in the Hospital Outpatient Prospective Payment System (HOPPS) Final Rule for Calendar Year 2018

…Consistent with its modernization of the date of service regulations, C21 respectfully requests that CMS update its policy for packaging laboratory tests furnished in the outpatient setting, to ensure that all tests with a different pattern of clinical use that make them less tied to the primary outpatient service than the routine laboratory tests that the agency packages are treated equally for purposes of packaging and the new laboratory date of service exception – including all multianalyte assays with algorithmic analyses (MAAAs). In addition, we urge the agency to release the application for designation of a test as an Advanced Diagnostic Laboratory Test (ADLT) under Section 216 of the Protecting Access to Medicare Act (PAMA) of 2014, in order to ensure that this component of the new, market-based payment system is able to take effect in accordance with the regulatory schedule on January 1, 2018.

Letter to CMS Regarding Implementation of CLFS Private Payor Rate-Based Payment Amounts for Calendar Year 2018

We write in support of the implementation of the private payor rate-based payment amounts for CY 2018 under the Clinical Laboratory Fee Schedule (CLFS). We commend the agency on its efforts to implement the provisions of Section 216 of the Protecting Access to Medicare Act of 2014 (PAMA) and the Medicare Clinical Diagnostic Laboratory Tests Payment System Final Rule (CLFS Final Rule). C21 supports the on-schedule implementation of private payor rate-based payment amounts for CY 2018 effective January 1, 2018, and believes that maintaining this effective date is critical to fulfill PAMA’s goals of improving the transparency and predictability of the CLFS rate-setting process. In addition to implementing the market-based rates effective January 1, we also respectfully request that the agency immediately release the application for Advanced Diagnostic Laboratory Test (ADLT) classification and a streamlined designation process to ensure that appropriate tests can be designated as new ADLTs effective January 1, 2018.

Letter in Response to the Centers for Medicare & Medicaid Services Physician Fee Schedule Proposed Rule for Calendar Year 2018 (Implementation of Medicare Clinical Diagnostic Laboratory Tests Payment System)

On behalf of the Coalition for 21st Century Medicine (C21), we appreciate the opportunity to comment on the CY 2018 Physician Fee Schedule Proposed Rule. We are writing in response to the Centers for Medicare & Medicaid Services’ (CMS’) solicitation of public input on the implementation of the new private payor-rate based Medicare Clinical Diagnostic Laboratory Tests Payment System promulgated under Section 216 of the Protecting Access to Medicare Act of 2014 (PAMA). C21 appreciates the work that CMS has performed over the past year in implementing PAMA’s private payor rate-based Clinical Laboratory Fee Schedule (CLFS). We continue to support the implementation of PAMA on the schedule set out in the CLFS Final Rule, which sets an effective date of January 1, 2018 for the new market-based payment rates. Additionally, we respectfully request that CMS release the application for Advanced Diagnostic Laboratory Test (ADLT) status as soon as practicable to enable qualifying tests to be designated in advance of CY 2018.

Letter in Response to the Centers for Medicare & Medicaid Services Hospital Outpatient Prospective Payment System Proposed Rule for Calendar Year 2018

On behalf of the Coalition for 21st Century Medicine (C21), we appreciate the opportunity to submit our comments in response to the Centers for Medicare & Medicaid Services (CMS) Hospital Outpatient Prospective Payment System (HOPPS) Proposed Rule for Calendar Year 2018. In particular, we are writing in support of the agency’s effort to modernize its Date of Service (DOS) billing policies for separately payable molecular pathology and Advanced Diagnostic Laboratory Tests (ADLTs) under Section 1834A(d)(5) of the Social Security Act that are performed on specimens collected from hospital outpatients. We agree with CMS that the current policy, as applied to these innovative tests, can create barriers to patient access to critical diagnostics and to the development of precision medicine, and that it is at odds with the agency’s rationale for excluding these tests from laboratory packaging in the hospital outpatient setting.