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 CMS Regarding Revisions to Payment Policies under the Physician Fee Schedule and Other Changes to Part B Payment Policies for the Calendar Year 2021

On behalf of the Coalition for 21st Century Medicine (C21), we appreciate the opportunity to comment on the Medicare Physician Fee Schedule (MPFS) Proposed Rule for Calendar Year 2021.

C21 comprises many of the world’s most innovative diagnostic technology companies, clinical laboratories, physicians, venture capital companies, and patient advocacy groups. C21’s mission is to improve the quality of healthcare by encouraging research, development, and commercialization of innovative diagnostic technologies that will personalize patient care, improve patient outcomes, and substantially reduce healthcare costs. For fifteen years, C21 has worked with CMS on the development, promulgation, and implementation of policies intended to facilitate appropriate patient access to high-quality clinical laboratory tests.

Letter to CMS Regarding the Laboratory Date of Service and Packaging Policy in the Hospital Outpatient Prospective Payment System (HOPPS) Proposed Rule for the Calendar Year 2021

On behalf of the Coalition for 21st Century Medicine (C21), we appreciate the opportunity to comment on the Hospital Outpatient Prospective Payment System (HOPPS) Proposed Rule for Calendar Year 2021. We strongly support the existing laboratory date of service (DOS) policy at 42 CFR 414.510(b)(5) which has expanded beneficiary access to innovative diagnostic testing since implementation in 2018. Likewise, C21 strongly supports CMS’ proposal to update the laboratory DOS policy and packaging policy exclusion to include cancer-related protein-based multi-analyte assays with algorithmic analyses (MAAA) tests. We believe this revision will promote similar billing jurisdiction rules for tests that are unrelated to the primary hospital outpatient service. To best promote the consistent application of the laboratory DOS policy, we respectfully recommend two updates to the agency’s proposal: 1. Confirm that the laboratory DOS policy and packaging policy exclusion apply to MAAA tests described by Proprietary Laboratory Analyses (PLA) codes; and 2. Make the laboratory DOS policy and packaging policy exclusion applicable to all MAAA tests if they are unrelated to the primary hospital outpatient service.

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.