The Pro's and Con's of Coding Approaches

 ProCon
Current Coding Approach +   Coding system changes rarely. +   New codes are carefully scrutinized for necessity & for conflicts or “interface” with existing codes. +   Infinite range of genomic tests can be coded by a small number of fixed codes (e.g. “gene amplification”)  +   System is stable and uniform nationally.  +     Payor need to distinguish among services (panel X, panel Y) is unmet.  Recent two-places modifiers fail to meet this need. +      Timeline to new code is lengthy. +     Uncertainty about so-called “politics” of code creation. +     Delay in new codes raises administrative costs due to manual processing of “unclassified” codes.
Coding Proposal 1: Increase use of Category III codes (“temporary tracking codes”) for molecular tests.Mechanism is in place; revisions annually; barrier to entry not high.Codes are by definition temporary, so this is not a long-term solution. Reports of payor bias against paying Category III codes.
Coding Proposal 2: Increase use of Level II (HCPCS) codes for molecular tests. Codes could be updated separately from the AMA CPT process.Level II codes (except S codes) are managed by CMS, which has limited administrative resources. CMS issues procedure codes primarily for clear programmatic need, e.g. to edit services under an NCD.
Coding Proposal 3: Establish new code set, more similar to NCD codes for specific drugs.Rapid and specific identification of new test. System works well for drugs (NCD system) and consumer products (UPC system.) Five-place codes using letters (LWXYZ) allows 12 million codes.Would require new national process; but some Congressional proposals have proposed a national multi-stakeholder committee to issue codes (and set prices).  Unless linked to some external validator, like FDA approval number, the exact process of test is uncertain.