Lab associations' endorsement of the "cross-walking" mechanism to set payment rates for six new clinical lab test codes signifies industry-wide skepticism of "gap-filling" as a viable alternative, according to AdvaMed.

The lack of enthusiasm for gap-filling reflects the limited resources carriers have to conduct the "extra work" entailed with the process, AdvaMed Associate VP-Payment & Policy Stephanie Mensh asserted at a July 28 CMS public meeting in Baltimore, Md. "It's a big concern all around," she said, suggesting test codes should be cross-walked "across the board."

The public meeting was held to gather input on whether the six new lab codes for the 2004 clinical laboratory fee schedule should be cross-walked or gap-filled. Decisions regarding the codes will be posted on CMS' website Sept. 10.

Cross-walking involves mapping the new tests to the most technically similar existing codes, while gap-filling requires local carriers to determine payment for the newly coded service for one year, as CMS collects cost data to assess an appropriate national limitation amount (NLA). The agency then sets the NLA at 100% of the mean of all carrier prices.

MCF Compliance President Charles Root, who represented the American Association of Clinical Chemistry at the CMS forum, had expressed similar concerns about gap-filling at AACC's conference in Philadelphia July 21-22, referring to the process as a "big unknown that can cause a lot of trouble."

Root criticized the gap-filling process for the delay it causes in setting a national payment rate, as well as for inaccurate payment amounts based on significant variation in the payment levels given to the Centers for Medicare & Medicaid Services by regional carriers and averaged by the agency.

Although carriers are supposed to use an empirical process to determine a payment amount using available information sources, "in reality, there is always a third of them that come up with stupid answers...which pulls the average down," Root maintained.

One possible remedy that could improve the gap-fill process is the contractor reform language in the Medicare reform bill, which could decrease the number of contractors from around 30 to six or eight, according to Don Thompson, director of CMS' division of ambulatory services. "If you reduce the number of entities examining the gap-fill...you probably reduce the variation," he noted during a lab reimbursement policy discussion (see ¹ Also see "CMS Lab Public Meeting Discussion Centers On Payment Policy Issues" - Medtech Insight, 4 August, 2003.).

Overall, the lab associations were in agreement regarding most of the CPT codes to be used for cross-walking the new tests. However, the Clinical Laboratory Management Association and the American Clinical Laboratory Association recommended that CPT code 8505X (reticulated platelet assay) be cross-walked to CPT code 88180 TC - a code used in the physician fee schedule.

The College of American Pathologists, the American Society of Clinical Pathologists and AACC, meanwhile, advocated cross-walking the test to CPT code 86361 - a code used in the clinical lab fee schedule code.

"We recommend [CPT code 86361] primarily... because of the difficulty of going outside the laboratory fee schedule," Root said. "The fee on [86361] is a more appropriate fee than the technical component of the physician fee schedule," he added.

Thompson commented that the agency does not normally consider using codes outside the lab fee schedule, but he said CMS "will take the comment into account and discuss it."

Other CPT codes under consideration this year include: 8415X1 (protein; total, except by refractometry; urine 8415X2 (protein, total, except by refractometry; other source); 8726X (infectious agent antigen detection by immunofluoroscent technique; giardia); 8732X (infectious agent antigen detection by enzyme immunoassay technique; qualitative or semiqualitative, multiple step method, giardia); and 8766X (trichomonas vaginalis, direct probe technique).

CMS will issue a program memo to carriers in November, and the codes will take effect Jan. 1, 2004.

While the test codes were fairly straightforward this year, less consensus could occur in 2004 when a code for the $30 modified albumin test is added to the lab fee schedule. Speaking at an AACC teleconference in March, Root predicted Ischemia Technologies' Albumin Cobalt Binding ( ACB ) test will be cross-walked to the CPT code for B-type natriuretic peptide tests with a $47 reimbursement rate (² Also see "ACB Cardiac Marker May Receive Same Reimbursement Rate As BNP – Root" - Medtech Insight, 24 March, 2003., p. 23).

Cross-Walking Urged For Six Lab Test Codes By Laboratory Societies

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