10/2018: Final Gapfill Pricing, Comments View (For CY2019)

0001U	$                        720	Red blood cell antigen typing, DNA,	Contractors looked at payment rates for similar tests on the CLFS (i.e. 81403) and also payment amounts derived from outside payer of the service.
0002U	$                          25	Oncology (colorectal), quan assessment of 3 urine metabolites	Contractors used the cost per test as indicated by the company, minus the cost of shipping and sales/education and 18% discount already offer by the laboratory.  Other contractors based recommendation on similar urine assessment tests on the CLFS.
0009U	$                        107	Oncology (breast cancer), ERBB2 (HER2) copy number by FISH	Contractors used the payment amount based on HER2 FISH code 88367 as a similar test.  Some contractors adjusted the fee to reflect 2018 RVUs.
0010U	$                        427	Infectious disease (bacterial), strain typing by WGS	Some contractors used the payment amount of a similar test on the CLFS (87153) and adjusted the fee to reflect 2018 RVUs. Other contractors recommended code 87153 as a similar test but recommended a multiplier of 3.
0012U	$                    2,516	Germline disorders, gene rearrangement detection by WGS	Some contractors used payment rates of a similar test on the CLFS, code 81445.  Others used commercially available service rates of $349.00.  Other contractors used information from a similar code being gapfilled, 81425, to estimate a payment rate recommendation.  They reasoned that since 0012U  examines the whole genome, but only detects large scale mutations, the payment rate should be estimated at 81425 x 0.5.
0013U	$                    2,516	Oncology (SO neoplasia), gene rearrangement detection by WGS	Some contractors used payment rates of a similar test on the CLFS, 81445.  Other contractors used information from a similar code being gapfilled, 81425, to estimate a payment rate recommendation.  They reasoned that since 0012U examines the whole genome, but only detects large scale mutations, the payment rate should be estimated at 81425 x 0.5.
0014U	$                    2,516	Hematology (hematolymphoid neoplasia), gene rearrangement detection by WGS	Some contractors used payment rates of a similar test on the CLFS, 81445.  Other contractors used information from a similar code being gapfilled, 81425, to estimate a payment rate recommendation.  They reasoned that since 0012U  examines the whole genome, but only detects large scale mutations, the payment rate should be estimated at 81425 x 0.5.
81327	$                        192	SEPT9 (Septin9) methylation analysis	Contractors used the average of two similar tests on the CLFS.  Specifically, they used the payment amount provided by a laboratory for code 81287 and the commercially available payment amount provided by a laboratory for code 81288.
81471	$                        914	X-linked intellectual disability dup/del, 60 Genes	Contractors used the average of the payment amount for a similar test on the CLFS, 81433, and the payment amount recommended by the laboratory.
81470	$                        914	X-linked intellectual disability (XLID) 60 Genes	Contractors used an average of the payment rate for a similar test on the CLFS, 81445, and a publically recommended payment amount.
81551	$                    2,030	Oncology (prostate), profiling by real-time PCR of 3 genes	Recommended payment rate based on company information and applied a 15% discount that was being offered by the provider.
0004M	$                          79	Scoliosis dna alys	Contractors based payment rate recommendation on commercial lab charges.  Contractors further explained that resources required for this test are comparable or relevant from labs with similar tests.
0006M	$                        150	Onc hep gene risk classifier	Contractors based payment rate recommendation on commercial lab charges.  Contractors further explained that resources required for this test are comparable or relevant from labs with similar tests.
0007M	$                        375	Onc gastro 51 gene nomogram	Contractors used 50% of the publically available rate.  No data were received from the laboratory when requested.
0009M	$                        133	Fetal aneuploidy trisom risk	Contractors used 50% of the publically available rate.  No data were received from the laboratory when requested.
81425	$                    5,031	Genome sequence analysis	Some contractors based initial recommendations on laboratories with similar test with charges of $349.00. Upon further review, however, several contractors revised their recommendations.  Some contractors looked to similar tests on the CLFS, specifically 81415, a Whole Exome Sequencing code, and adjusted the payment rate based on input from several laboratories.  Other contractors simply followed public recommendations to use CPT 81415 as a similar test on the CLFS to recommend a payment rate.
81426	$                    2,710	Genome sequence analysis, each comparator genome	Some contractors based initial recommendations on laboratories with similar test with charges of $349.00. Upon further review, however, several contractors revised their recommendations.  Some contractors looked to similar tests on the CLFS, specifically 81415, a Whole Exome Sequencing code, and adjusted the payment rate based on input from several laboratories.  Other contractors simply followed public recommendations to use CPT 81415 as a similar test on the CLFS to recommend a payment rate.
81427	$                    2,338	Genome re-evaluation	Initially, several contractors felt this code represented interpretation only and thus averaged two comparable codes (G0452-26 and 88291).  Upon further review, some contractors followed public recommendations to use CPT 81417 as a similar test on the CLFS. Others did not recommend this similar payment rate and instead estimated a professional labor rates for the code.