Tempest in the Melting Pot: Genomics Reimbursement in 2012


In This Issue:

Introduction; The World of Yesterday; Cracks in the System Widen; A Rumble on the Mountain - 1. Reimbursement for genetic laboratory tests and 2. Handling of high-value genomic tests; What May Happen Next - 1. Will genomic tests move to the physician fee schedule? No. and 2. Will CMS use the new genetic codes in 2012? No. and 3. Will the AMA Coding Process Consider IVDMIAs? Uncertain.


The core set of genetic test codes used by U.S. insurers and Medicare date to 1993. Only general information is conveyed by these codes to insurers – “DNA probe x 2.” They lead to payment for genetic tests based on a fixed price per genetic test step (such as “DNA probe x 2” or “DNA amplification x 3”). The payment was set using rules for the Medicare clinical laboratory fee schedule, rules which date to 1984.

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DISCLAIMER: Because of the generality of this update, the information provided herein may not be applicable in all situations and should not be acted upon without specific legal advice based on particular situations.

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