29. Reimbursement for molecular pathology testing for neoplasia: The 2024 update

Abstract

Chromosome genomic array testing (CGAT), targeted mutation NGS, and targeted RNA sequencing (TRS) are incorporated in the pathway testing scheme for hematologic disorders at our institution. Previously, we shared the reimbursement landscape of CGAT and mutation NGS for FY-17. Here we present an update for FY-18 to FY-23, encompassing CGAT (HCPCS 81406 and 81277), mutation NGS (81450 and 81455), and TRS (81455). Compared with FY-17, FY-18 to FY-23 showed improved percent of cases reimbursed for CGAT. Six-year average percentage of cases reimbursed showed 68% (yearly range: 58% to 80%) for CGAT, 74% (69% to 92%) for mutation NGS under 81450, and 76% (50% to 81%) for mutation NGS and TRS under 81455. The percentage of cases reimbursed varied between payers: CGAT/NGS had 82%/71% by commercial payers, 65%/70% by Medicaid, and 53%/83% by Medicare. The payer mix varied between years with the median payer percentage of commercial payers at 52% (45 to 57%), Medicare at 32% (25 to 45%), and Medicaid at 11% (7 to 15%). Out of 33 TRS studies billed, 20 cases were reimbursed (61%), including 9 out of 11 (82%) by commercial, 7 out of 14 (50%) by Medicare, and 4 out of 5 by Medicaid (80%). In conclusion, our assessment of percentage of claims receiving payment suggests improved reimbursement landscape for molecular assays over time with a trend showing more success with commercial payers than Medicare and Medicaid as well as higher percentage of cases being reimbursed for mutation NGS than for CGAT.