Government is full of crap on COVID-19 testing

[LADoc00]

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I cant believe the level of total utter chaos in the COVID-19 testing sphere, something every country has been able to figure out without much trouble.

To recap:
~Trump said testing would be free for those who want it
~Gavin Newsom said there would be NO co-pay
~Pence now says that even UNINSURED will get the test for free

Fine, fine I get this is totally steamrolling...

CMS is real **** disturber of this theater of the absurd released a guidance in 2018 basically saying they would pay NOTHING for multiplex PCR of more than 5 respiratory pathogens. NOTHING.
That eliminates any panel test such as BioFire or Cepheid from being used.
And BioFire Defense has 1 MILLION test kits stored up in Utah. 1 MILLION. All useless due to CMS. Yes you read that right: ONE MILLION COVID-19 KITS their sales folks are frantically trying to offload to suckers because any kit with more than 5 pathogens onboard is USELESS per CMS. And in that guidance, BioFire which builds all the kits for the military is actually mentioned by NAME! Insane. The sales folks for BioFire are trying to get in front of anyone who will convince hospitals to buy them, nurses, pathologists, random lab people...it's crazy and sad.

THEN, CMS releases a new guidance and CPT for COVID-19 testing...U0002 CPT...with a whopping $51.33 payment attached to it....WHAT?!?%$#@(&$#%*&YY#$&

The test kits can be as much as 100+ bucks, the analyzers 40-200K, the NP swabs with TM are MASSIVELY EXPENSIVE NOW. Quest and Labcorp's LDT is priced at over $250!#*$& #*)($& #$*)&

And CMS is paying just 51 bucks and change? Is this a total joke? Am I in some crazy nightmare where toilet paper is the new currency and everyone is totally insane?

DO NOT ENGAGE IN COVID TESTING AT YOUR LAB. IT'S A TRAP!!! NO ONE IN GOVERNMENT INTENDS TO PAY YOU FOR IT!!!!!

 

[deleted480308]

Govt shouldn’t be running around promising free stuff

 

[LADoc00]

Govt shouldn’t be running around promising free stuff

Normally yes, but under current circumstances this is gonna collapse the entire government. Boogaloo2020.

 

[CDX-2]

Sorry for my naivety,

are there private insurance companies that are willing to pay something on top of the CMS for Coronavirus testing to the testing labs?

 

[bauber]

The current Biofire panels do not detect COVID19 but they are developing an update that will include it if I am not mistaken.

 

[Napoleon1801]

And CMS is paying just 51 bucks and change? Is this a total joke? Am I in some crazy nightmare where toilet paper is the new currency and everyone is totally insane?

DO NOT ENGAGE IN COVID TESTING AT YOUR LAB. IT'S A TRAP!!! NO ONE IN GOVERNMENT INTENDS TO PAY YOU FOR IT!!!!!

Numbers look correct to me. Syndromic testing and the Biofire panel are the wave of the future and of course CMS doesn't want to pay for it.

And $51 reimbursement for the COVID-19 test?? That's going to be fun when we're testing half our community at this rate...

 

[Napoleon1801]

The current Biofire panels do not detect COVID19 but they are developing an update that will include it if I am not mistaken.

An update or a separate cartridge? I've only seen a press release that it might be available 2nd quarter.

 

[Iceman24]

Thank you for sharing. These are great news.
I hope this will prevent/significantly reduce utilization of testing since it has no clinical significance in outpatient setting and very little in inpatient.

 

[Med Director New England]

Numbers look correct to me. Syndromic testing and the Biofire panel are the wave of the future and of course CMS doesn't want to pay for it.

And $51 reimbursement for the COVID-19 test?? That's going to be fun when we're testing half our community at this rate...

not 51
~ 285.00

 

[LADoc00]

The current Biofire panels do not detect COVID19 but they are developing an update that will include it if I am not mistaken.

BioFire Defense arm has the kit and stockpiled the dry reagents. And yes this isnt technically public knowledge at the current time.

$285 WAS the reimbursement for 1 pathogen PCR. But I dont think that is what they will pay now. If so, why create U0002?!?

 

[LADoc00]

Thank you for sharing. These are great news.
I hope this will prevent/significantly reduce utilization of testing since it has no clinical significance in outpatient setting and very little in inpatient.

Yes but entire companies are closing now because of an unconfirmed contact or a random secretary with the season cold or allergies. I know of one company that might collapse because a coughing employee had smoked too much weed on their break and everyone just left the jobsite immediately..

 

[Med Director New England]

BioFire Defense arm has the kit and stockpiled the dry reagents. And yes this isnt technically public knowledge at the current time.

$285 WAS the reimbursement for 1 pathogen PCR. But I dont think that is what they will pay now. If so, why create U0002?!?

I was just on a call with BC/BS. It is 285.
The new code was created so the payers will not bill the patient. The generic code can’t be differentiated from other pathogens.

 

[LADoc00]

I was just on a call with BC/BS. It is 285.
The new code was created so the payers will not bill the patient. The generic code can’t be differentiated from other pathogens.

Oh wow, THANK YOU.

What about CMS though??? That is what I am concerned about.

 

[Med Director New England]

Oh wow, THANK YOU.

What about CMS though??? That is what I am concerned about.

It looks like all payers including gov’t will pay the same price - 285.

 

[WEBB PINKERTON]

I can't quit laughing looking at that Admiral Ackbar gif

 

[Iceman24]

Yes but entire companies are closing now because of an unconfirmed contact or a random secretary with the season cold or allergies. I know of one company that might collapse because a coughing employee had smoked too much weed on their break and everyone just left the jobsite immediately..

All the companies should start working remotely/close business ASAP anyway and it has nothing to do with whether the testing is available or not.

 

[Napoleon1801]

Thank you for sharing. These are great news.
I hope this will prevent/significantly reduce utilization of testing since it has no clinical significance in outpatient setting and very little in inpatient.

I would tend to disagree on the misutilization point. For us, the syndromic PCR panels are much more efficient and economical as opposed to the clinician guessing at expensive send-outs. These panels are fast to run (<1.5 hrs), get a meaningful result to the provider, and gives us a heads up on community outbreaks. Additionally, with a quick answer we don't have to perform unnecessary cultures/sensitivities.

 

[Iceman24]

get a meaningful result to the provider

No way, no specific treatment is available and the only prophylaxis is isolation regardless whether you sick or healthy. If you need vent then you vented anyway.

gives us a heads up on community outbreaks

Who are "us"?
I think Italy gave US enough of a heads up to guess that strict quarantine should be enforced ASAP. No, we have to spend billions of dollars to get more heads up. Just insane.

Or someone will seriously think huge lines of people waiting to be tested in an outpatient setting is good??

 

[gbwillner]

You can learn about the CMS rationale for the coverage on respiratory viral pathogens panels by looking at the coverage determinations on the Medicare Coverage Database. It's free.

Unless you are an infectious disease expert in the ICU, there is no utility in more than 5 pathogens. Even IF these panels detect coronavirus they are overkill to look for a single (or 2 strains) of a virus. CMS pricing is exactly the same as testing for other similar viruses including zika.

 

[Napoleon1801]

No way, no specific treatment is available and the only prophylaxis is isolation regardless whether you sick or healthy. If you need vent then you vented anyway.



Who are "us"?
I think Italy gave US enough of a heads up to guess that strict quarantine should be enforced ASAP. No, we have to spend billions of dollars to get more heads up. Just insane.

Or someone will seriously think huge lines of people waiting to be tested in an outpatient setting is good??

Sorry for the confusion, I was referencing the entire respiratory PCR panel available from Biofire, not just the COVID test.

 

[Napoleon1801]

You can learn about the CMS rationale for the coverage on respiratory viral pathogens panels by looking at the coverage determinations on the Medicare Coverage Database. It's free.

Unless you are an infectious disease expert in the ICU, there is no utility in more than 5 pathogens. Even IF these panels detect coronavirus they are overkill to look for a single (or 2 strains) of a virus. CMS pricing is exactly the same as testing for other similar viruses including zika.

I've read it, but we do have internal data that has demonstrated overall cost reduction in care. We submitted it for the last coverage determination, but it was dismissed.

 

[gbwillner]

I've read it, but we do have internal data that has demonstrated overall cost reduction in care. We submitted it for the last coverage determination, but it was dismissed.

CMS does not consider cost in coverage determinations outside of what is "reasonable and necessary". System cost reduction is NOT an acceptable rationale for coverage for services. This is not about reason but about law as it pertains to the administration of Medicare.

 

[Napoleon1801]

CMS does not consider cost in coverage determinations outside of what is "reasonable and necessary". System cost reduction is NOT an acceptable rationale for coverage for services. This is not about reason but about law as it pertains to the administration of Medicare.

The total cost of care is something one cannot ignore. At-risk contracts are becoming more common and will probably start to change the narrative soon. A physician ordering a respiratory cultures and multiple viral tests (flu/metapneumo/corona/parainfluenza/adenovirus) costs significantly more than running a single film array. This has saved us admissions and has been a valuable rule out tool in the current COVID crisis. This test is very much reasonable and necessary.

 

[gbwillner]

If you want to run a virus panel and doing so is indicated and reasonable and necessary, run one. This is covered under the respiratory viral panel policy.

 

[LADoc00]

It looks like all payers including gov’t will pay the same price - 285.

New England,

THIS IS FALSE. CMS has confirmed they are ONLY paying on the U0002 for all non-CDC Covid-19 tests and not 87635 REGARDLESS OF METHODOLOGY.

I REPEAT REGARDLESS OF METHODOLOGY YOU GET ONLY 51 DOLLARS FOR A TEST WHICH COSTS SEVERAL TIMES THAT.

Only non-CMS commercial payers are able to be billed for 87635.

Worried yet?

 

[Med Director New England]

Just edited this after doing a little legwork.
the price for testing has been steadily dropping as labs started with the modifiedCDC method and then Switched to roche. Most payers are getting preferred pricing sound 75 80 bucks currently.

and yes cms rate is now lower - LA your number is correct for now at least. 285 with the roche platform would be way to high based on the actual cost to run test. I am also hearing the big labs still don’t know their actual cost and they basically have Pense on speed dial, so I am sure in the end they’ll be ok and so will the suppliers of the test components.

I am not feeling to sorry for the large commercial labs running 24/7 using the roche 8800, which most have migrated too. one machine can run almost 2500 day. With normal payer mix the big boys will be fine. They Will likely be hurt a bit b/c every test not Covid, flu or RVP is way down.

a fair amount of paid for tests will be run on impatients anyways with DRG rules. So labs will be collecting somewhere between 51 and 285 from hospitals that don’t have in house or in system ability to run Covid testing.

mentioned this before - wouldn’t be surprised if a concierge model pops up. You pay more you get your test quicker.

The hospitals are probably the most screwed financially in all of this. Some MDs too. I think many employed MDs who are not capable of doing real inpatient work will be furloughed.

An employed path somewhere else was celebrating their easy days with Covid. If you are a pahtologist with nothing to do know look out too.

 

[gbwillner]

New England,

THIS IS FALSE. CMS has confirmed they are ONLY paying on the U0002 for all non-CDC Covid-19 tests and not 87635 REGARDLESS OF METHODOLOGY.

I REPEAT REGARDLESS OF METHODOLOGY YOU GET ONLY 51 DOLLARS FOR A TEST WHICH COSTS SEVERAL TIMES THAT.

Only non-CMS commercial payers are able to be billed for 87635.

Worried yet?

LA,
Sorry, but this is just misinformation. The CMS communication of the U0001 and U0002 codes predated the AMA creation of the CPT code 86735 and was done as an emergency remedy to create a specific code for this test. No communication has gone out by CMS as a national policy to preclude payment for this CPT code.

 

[LADoc00]

LA,
Sorry, but this is just misinformation. The CMS communication of the U0001 and U0002 codes predated the AMA creation of the CPT code 86735 and was done as an emergency remedy to create a specific code for this test. No communication has gone out by CMS as a national policy to preclude payment for this CPT code.

If I follow along with your line of reasoning and if you look the CPT communication on 86735 has no precise date/time stamp as far as I can tell to back up your analysis, WHY would CMS create a new U0002 to sow confusion at the worst possible time if they merely intended us to use a new nucleic acid testing code just days or even hours later?

You may very well be correct and I hope you are, but this is far far from being crystal clear.

 

[gbwillner]

If I follow along with your line of reasoning and if you look the CPT communication on 86735 has no precise date/time stamp as far as I can tell to back up your analysis, WHY would CMS create a new U0002 to sow confusion at the worst possible time if they merely intended us to use a new nucleic acid testing code just days or even hours later?

You may very well be correct and I hope you are, but this is far far from being crystal clear.

The CMS communication came first with an effective date of 4/1, meaning they expected you to hold claims until this date. They were not aware and had no way to know what the AMA was doing. What they knew was there was no way to bill specifically for COVID-19, and there is a lot of fraud and abuse around viral pathogen testing, and they likely did not want claims denied as many edits are in place to prevent unnecessary viral pathogen tests. This code was created so labs could bill specifically for this pathogen, and they hoped that having such a code would help track case numbers. Then a few weeks later AMA scrambled to make an emergency CPT code that did basically the same thing. I agree it's confusing but it was due to the fact that you have two completely unrelated organizations trying to solve the same problem. The AMA made the effective date 3/14 because they dont have to deal with claims processing, so maybe that made it appear to predate the CMS communication.

 

[LADoc00]

LA,
Sorry, but this is just misinformation. The CMS communication of the U0001 and U0002 codes predated the AMA creation of the CPT code 86735 and was done as an emergency remedy to create a specific code for this test. No communication has gone out by CMS as a national policy to preclude payment for this CPT code.

Yup as a I fully expected on what? March 15th, the government IS NOT PAYING ON CODES FOR COVID TESTING OTHER THAN THE NEW U CODES.

No clue from whom you got your information originally but but if you try to bill 86735 and are caught, you are HOSED. Indeed as I suspected and inferred from their communications all the way to early March, they fully intended to tank reimbursements for tests on the Cepheid/Biofire platforms from 285 all the way down to 100 with expectations you had to make up for it on volumes.

So misinformation back at you GB, not sure if you realized this after you posted.

 

[gbwillner]

Yup as a I fully expected on what? March 15th, the government IS NOT PAYING ON CODES FOR COVID TESTING OTHER THAN THE NEW U CODES.

No clue from whom you got your information originally but but if you try to bill 86735 and are caught, you are HOSED. Indeed as I suspected and inferred from their communications all the way to early March, they fully intended to tank reimbursements for tests on the Cepheid/Biofire platforms from 285 all the way down to 100 with expectations you had to make up for it on volumes.

So misinformation back at you GB, not sure if you realized this after you posted.

Dude, LA, I thought you were SC material. You need to chill. You are making some pretty bold claims here- please point us to any CMS communication stating that they are not paying for 86735. BTW, that is Mumps antibody testing, so if you are billing that for a patient with respiratory distress, it is not CMS' fault that you are performing an unnecessary service and probably should not be getting paid.

The correct code for COVID-19 is 87635. That is covered by CMS. They even put out a communication about it- see here:

https://www.cms.gov/files/document/03052020-medicare-covid-19-fact-sheet.pdf

but go ahead and continue to rant about my misinformation. Maybe go outside for a walk or something.

 

[LADoc00]

Dude, LA, I thought you were SC material. You need to chill. You are making some pretty bold claims here- please point us to any CMS communication stating that they are not paying for 86735. BTW, that is Mumps antibody testing, so if you are billing that for a patient with respiratory distress, it is not CMS' fault that you are performing an unnecessary service and probably should not be getting paid.

The correct code for COVID-19 is 87635. That is covered by CMS. They even put out a communication about it- see here:

https://www.cms.gov/files/document/03052020-medicare-covid-19-fact-sheet.pdf

but go ahead and continue to rant about my misinformation. Maybe go outside for a walk or something.

Hahaha. Im chill bud but wasted like 90 minutes arguing with government officials yesterday before I got this:

Thank you for your email. Medicare will only pay the four U codes. Medicare will not pay the three CPT codes as these are essentially the same as the U codes. The commercial carriers will pay the CPT codes we expect.
Medicare Rates:

U0001- $35.91

Laboratory testing of Medicare patients using the Centers for Disease Control and Prevention (CDC) 2019 Novel Coronavirus Real Time RT-PCR Diagnostic Test Panel, will be billed with HCPCS code U0001. This code will only be used for tests developed by the CDC.


U0002- $51.31

Laboratories performing non-CDC laboratory tests of Medicare patients for COVID-19 will bill for them using a different HCPCS code, U0002.

U0003- $100.00


U0003 Infectious agent detection by nucleic acid (DNA or RNA); sever acute respiratory syndrome coronavirus 2 (SARS-CoV-2)(Coronavirus disease [COVID-19]), amplified probe technique, making use of high throughput technologies as described by CMS-2020-01-R

 U0003 should be used to identify tests that would otherwise be identified by CPT code 87635 but for being performed using high throughput technologies.


U0004- $100.00


U0004 2019-nCoV Coronavirus, SARS-Co-V-2/2019-nCoV (COVID-19), any technique, multiple types of subtypes (includes all targets), non-CDC, making use of high throughput technologies as described by CMS-2020-01R

 U0004 should be used to identify tests that would otherwise be identified by U0002 but for being performed using high throughput technologies.

86328- $0

86769- $0

87635- $0

After this response, I then backtested this with path groups who own their CP labs to see if they had indeed been paid out on any COVID-19 related 87635 and the few who had were then required to pay those funds back and resubmit claims using U codes. "High throughput technologies" is defined as any platform capable of more than 1 specimen being processed at a time whether or not you have the additional slots on your own analyzer for multiplex analysis.

Im not being toxic, just want to get the word out there about what is actually happening in the field.

As far as I can tell and I've ran the numbers on this a dozen times since mid March, I do not see any profit potential whatsoever in commercial testing unless you can sell cash direct to consumer. The problem is people doing this are now running afoul of CMS if they are caught.

 

[gbwillner]

Maybe you should forward the letter I posted above to whomever you spoke with. I assume someone at the provider call center at Noridian? forward their response to their Medical Director.

BTW, what difference does it make- bill U0002.

 

[LADoc00]

Maybe you should forward the letter I posted above to whomever you spoke with. I assume someone at the provider call center at Noridian? forward their response to their Medical Director.

BTW, what difference does it make- bill U0002.

U0002 doesnt even pay the cost of reagents, its 51.31. NP swab + Biofire/Cepheid kit and fractional QC cost is more than 50 bucks now.

And that came from the medical director of my region, Jurisdiction D.

 

[gbwillner]

Is that Cepheid kit for a single sample? Do you run a high-complexity lab? RT-PCR tests are easy to create LDTs for....

Also, not sure where Jurisdiction D is- I think that is a DME jurisdiction. If you are California Part B is J1. What Med Director sent you that info???

 

[LADoc00]

My bad Im Jurisdiction E (California/Nevad, JE) not D and I think and this was a response I think from JD. It was forwarded to me, I didnt personally correspond but an appropriate analogy to U coding would be G coding. For months after the first prostate G codes appeared, groups continued to try to bill 88305s thinking this didnt apply to them but it cleary was intended to.

U codes are not intended for LDTs aside from the CDC supplied kit codes, right? LDTs have their own payment pathing, hence why I think Quest and Labcorp are killing it right now while community hospitals are losing money on testing. This is absolutely by intent.

Not putting on a tinfoil hat or anything, but why create U codes when 87635 already existed and they could "capture" important epidemiology data by using standard ICD coding?? None of that from your letter makes sense.

 

[gbwillner]

My bad Im Jurisdiction E (California/Nevad, JE) not D and I think and this was a response I think from JD. It was forwarded to me, I didnt personally correspond but an appropriate analogy to U coding would be G coding. For months after the first prostate G codes appeared, groups continued to try to bill 88305s thinking this didnt apply to them but it cleary was intended to.

These are HCPCS codes from CMS rather than AMA. That is the only difference.

Here is an explanation:

HCPCS Release & Code Sets | CMS

Access Healthcare Common Procedure Coding System (HCPCS) procedure and modifier codes, descriptions, and Medicare pricing data.

www.cms.gov

U codes are not intended for LDTs aside from the CDC supplied kit codes, right? LDTs have their own payment pathing, hence why I think Quest and Labcorp are killing it right now while community hospitals are losing money on testing. This is absolutely by intent.

Nope. U0001 is if you are using the CDC kit, but the other codes can be used with LDTs ("any method" is CLEARLY stated on U0002). Not sure where the idea comes from that "LDTs have their own payment pathing"... this is not based on anything.

Not putting on a tinfoil hat or anything, but why create U codes when 87635 already existed and they could "capture" important epidemiology data by using standard ICD coding?? None of that from your letter makes sense.

I think we already covered this one. U0001 and U0002 actually came first. CMS and AMA both created the codes at the same time and did not coordinate. They do the same exact thing- allow you to specify COVID-19 pathogen testing. Both are appropriate billable codes. There is NO DIFFERENCE between billing 8765 and U0002 to CMS. None.

/I will start charging next time for this consultation. I will give you this freebee because the DJIA is at 24,700+ right now and you are shorting. :^)

 

[Med Director New England]

All right now I am confused.

GB - is your lab doing Covid testing with modified high thru put CDC method (such as on roche platform) and still billing/collecting from cms the one pathogen PCR code ($285/patient)?

 

[LADoc00]

All right now I am confused.

GB - is your lab doing Covid testing with modified high thru put CDC method (such as on roche platform) and still billing/collecting from cms the one pathogen PCR code ($285/patient)?

This.
And from what I read back in 2018 when this was a huge CAP issue was that LDTs are individually negotiated reimbursements and arent not pathed to a CPT code reimbursement. Hence why when CMS tried to cap the maximal amount for different NGS platforms, the big commercial players flew into a panic as that was their core profit margin and had that rule retracted.

CMS Walks Back Coverage Decision on Laboratory Developed Tests | AACC.org


GB, now I could be wrong (I am NOT flawless in my understanding of this) but having been in academia, LDTs employ "CPT stacking" to come up a massive reimbursement for tests that community hospitals and lab pretty much never will have access to so Im not sure LDTs for COVID-19 are using a U code.

Are you billing $285 and getting paid for a PCR high complex or waived platform i.e. Cepheid or Biofire?? Because what I heard from multiple states is that many have tried, none have succeeded at least for CMS.

Im also confused now on your additional point, why we would care what guidance the AMA puts out because they dont pay on any claims?? Only CMS guidance matters, that entire line of reasoning makes zero sense to me.

 

[deleted314957]

These are HCPCS codes from CMS rather than AMA. That is the only difference.

Here is an explanation:

HCPCS Release & Code Sets | CMS

Access Healthcare Common Procedure Coding System (HCPCS) procedure and modifier codes, descriptions, and Medicare pricing data.

www.cms.gov

Nope. U0001 is if you are using the CDC kit, but the other codes can be used with LDTs ("any method" is CLEARLY stated on U0002). Not sure where the idea comes from that "LDTs have their own payment pathing"... this is not based on anything.




I think we already covered this one. U0001 and U0002 actually came first. CMS and AMA both created the codes at the same time and did not coordinate. They do the same exact thing- allow you to specify COVID-19 pathogen testing. Both are appropriate billable codes. There is NO DIFFERENCE between billing 8763 and U0002 to CMS. None.

/I will start charging next time for this consultation. I will give you this freebee because the DJIA is at 24,700+ right now and you are shorting. :^)

If LA is short i’ll bet he got a margin call last week!


Sent from my iPad using Tapatalk

 

[Med Director New England]

This.
And from what I read back in 2018 when this was a huge CAP issue was that LDTs are individually negotiated reimbursements and arent not pathed to a CPT code reimbursement. Hence why when CMS tried to cap the maximal amount for different NGS platforms, the big commercial players flew into a panic as that was their core profit margin and had that rule retracted.

CMS Walks Back Coverage Decision on Laboratory Developed Tests | AACC.org


GB, now I could be wrong (I am NOT flawless in my understanding of this) but having been in academia, LDTs employ "CPT stacking" to come up a massive reimbursement for tests that community hospitals and lab pretty much never will have access to so Im not sure LDTs for COVID-19 are using a U code.

Are you billing $285 and getting paid for a PCR high complex or waived platform i.e. Cepheid or Biofire?? Because what I heard from multiple states is that many have tried, none have succeeded at least for CMS.

Im also confused now on your additional point, why we would care what guidance the AMA puts out because they dont pay on any claims?? Only CMS guidance matters, that entire line of reasoning makes zero sense to me.

So I believe that high thru put was defined in the final cms rule earlier in April as instrumentation capable of running > 200 samples / day.

that would encompass both Roche platforms, hologic panther, and Abbot at least and probably others. Most labs would be using one of these 3.

as I understand it the final rule cms set the payment at 100 / sample for any high thru-put system, replacing the earlier rate of 50 ish and making it completely clear the one pathogen code could not be used anymore for ‘high thru-put’ platforms regardless of how many samples a lab actually runs.

this impacted a lot of payers that had negotiated with Q and LC preferred rates for their patients and hospitals who did the same for inpatient testing that had negotiated rates of 85-ish / sample. This became sub-Medicare after the April adjustment to the cms payment and these preferred rates had to be adjusted up.

 

[gbwillner]

This.
And from what I read back in 2018 when this was a huge CAP issue was that LDTs are individually negotiated reimbursements and arent not pathed to a CPT code reimbursement. Hence why when CMS tried to cap the maximal amount for different NGS platforms, the big commercial players flew into a panic as that was their core profit margin and had that rule retracted.

CMS Walks Back Coverage Decision on Laboratory Developed Tests | AACC.org


GB, now I could be wrong (I am NOT flawless in my understanding of this) but having been in academia, LDTs employ "CPT stacking" to come up a massive reimbursement for tests that community hospitals and lab pretty much never will have access to so Im not sure LDTs for COVID-19 are using a U code.

Are you billing $285 and getting paid for a PCR high complex or waived platform i.e. Cepheid or Biofire?? Because what I heard from multiple states is that many have tried, none have succeeded at least for CMS.

Im also confused now on your additional point, why we would care what guidance the AMA puts out because they dont pay on any claims?? Only CMS guidance matters, that entire line of reasoning makes zero sense to me.

OK, I won't spend too much time here, but let me correct a few misconceptions:

1. You cannot "code stack" to CMS for any one service. So it does not matter if it an LCT or FDA test, this is not allowed. This was allowed in the past but as you can imagine resulted in a lot of improper billing, abuse or worse.
2. the reimbursement for RT-PCR (amplified probe technique) for a single organism is $35-$51 and change. I don't know where you guys get $285 from- this is a "crosswalk" for every CPT code describing this exact service in similar respiratory viruses, such as influenza (87501), and Zika (87662). The higher-reimbursed codes are for multi-pathogen panels. We discussed these above. BTW, this is all in stone within the CLFS. No one can change these prices because of PAMA.
3. Claims processing requires the use of billing codes. It falls on AMA (loooong story) to make up the codes- it is a monopoly for them and I think by far the largest source of revenue for the organization as they are proprietary codes. CMS creates HCPCS codes when AMA codes are not available. There is a CPT code for amplified probe technique for pathogen NOS, but with COVID and the fact that there is abuse in this space, both AMA and CMS decided a specific code was needed. CMS created U0001 and U0002 while AMA made 87635. There was no conspiracy- both are real and billable codes.
4. LDTs are no different from a coverage perspective than FDA tests. This falls in the cracks of oversight and regulations and has nothing to do with coverage. You do not need to be in academia to run an LDT. In fact, ALL COVID-19 TESTS RIGHT NOW ARE LDTs.

 

[gbwillner]

So I believe that high thru put was defined in the final cms rule earlier in April as instrumentation capable of running > 200 samples / day.

that would encompass both Roche platforms, hologic panther, and Abbot at least and probably others. Most labs would be using one of these 3.

as I understand it the final rule cms set the payment at 100 / sample for any high thru-put system, replacing the earlier rate of 50 ish and making it completely clear the one pathogen code could not be used anymore for ‘high thru-put’ platforms regardless of how many samples a lab actually runs.

this impacted a lot of payers that had negotiated with Q and LC preferred rates for their patients and hospitals who did the same for inpatient testing that had negotiated rates of 85-ish / sample. This became sub-Medicare after the April adjustment to the cms payment and these preferred rates had to be adjusted up.

This is all correct except for the italicized part. Maybe I am being pedantic, but U0001/U0002 and 87635 are not replaced- they are still payable and independent, there is just a qualification for U0003/U0004 coverage. Of course, you'd be a sucker to NOT bill U0004 if you could.

 

[Med Director New England]

It looks like no matter how it is coded
Cms is paying $100 / sample if run on high thruput platform.

I have a lot of familiarity with the roche platforms and that is a fair rate considering the costs to run even with a modest volume.

see link. 87635, U code 1-4 all are 100 per most recent cms ruling. This could change.

https://www.cms.gov/files/document/cms-2020-01-r.pdf

 

[gbwillner]

It looks like no matter how it is coded
Cms is paying $100 / sample if run on high thruput platform.

I have a lot of familiarity with the roche platforms and that is a fair rate considering the costs to run even with a modest volume.

see link. 87635, U code 1-4 all are 100 per most recent cms ruling. This could change.

https://www.cms.gov/files/document/cms-2020-01-r.pdf

This is the right document but I don't think you are reading it right.

It says IF you are running a CLDT (basically LDT) FOR COVID-19 and are currently billing under U0002 or CPT 87635, AND you meet the definition in this document for a "high throughput" CLDT (you nailed it- can do more than 200 per day); THEN you may bill U0003 or U0004 (CPT vs HCPCS code) and get $100 per case. If you don't meet the definition of high throughput testing you have to bill U0002 or CPT 87635, and that pays $51.31.

 

[LADoc00]

GB I understand what your saying but in essence the government trapped COVID testing to single agent PCR by disallowing 87631 (where the $285 came from...dude I think you know that🙂 but I LOL'd at your comment of where that dollar amount came from.

This is very very important to understand as many vendors like Biofire baked the COVID PCR into a viral panel and set that price at 135+ per kit. If you cant bill 87631, you cant use all those kits they produced and are still producing unless you want to lose a ton of money per kit right?

Yes you can always buy a kit individually but the line for that product is out the door right? Why not expand what kits can be used to get more testing done quicker?

After listening to Osterholm Update which IMO is absolutely the best podcast, Im fairly convinced the entire mantra of "test, test, test" is completely useless.

So what testing gets paid what by who I have moved well past now.

 

[gbwillner]

GB I understand what your saying but in essence the government trapped COVID testing to single agent PCR by disallowing 87631 (where the $285 came from...dude I think you know that🙂 but I LOL'd at your comment of where that dollar amount came from.

This is very very important to understand as many vendors like Biofire baked the COVID PCR into a viral panel and set that price at 135+ per kit. If you cant bill 87631, you cant use all those kits they produced and are still producing unless you want to lose a ton of money per kit right?

Yes you can always buy a kit individually but the line for that product is out the door right? Why not expand what kits can be used to get more testing done quicker?

After listening to Osterholm Update which IMO is absolutely the best podcast, Im fairly convinced the entire mantra of "test, test, test" is completely useless.

So what testing gets paid what by who I have moved well past now.

LA, I am going to continue to be Capt Buzzkill here, so I apologize in advance. There are essentially 3 things wrong with what you are saying....

1. The CLFS price for 87631 is $142.63, not $285. The latter may be what BCBS pays, but it is not Medicare rate.
2. 87631 IS COVERED by CMS in your jurisdiction. However, the patient has to be in a hospital/urgent/acute care setting, not in an outpatient clinic where they are walking in. The point is that if someone is sufficiently sick that knowing the specific virus causing their respiratory illness will actually impact treatment (aside from COVID-19), then they should get this test. However, if the patient feels a sore throat and comes into the CPC, it is not essential to their care to get this panel. Now, it may be essential to test for COVID-19, but not the other viruses. If access is your concern, know that you could run the panel and just bill for 87635 if you wanted, which would lose you money. You could also just send to Quest/LabCorp for COVID-19 if you don't have that specific test by itself.
3- The BIG ONE- these panels actually don't test for COVID-19. My understanding is Biofire is looking to incorporate COVID-19 into their existing panel, but that won't roll out till July. So WHY are you running this panel????

 

[Allegri]

It's a good thing we don't have a government-run health care system, it would be such a bureaucratic socialist nightmare /sarcasm