A quarterly update for the Clinical Laboratory Fee Schedule (CLFS), issued May 4, includes nine new CPT® codes for proprietary laboratory analyses (PLAs). Medical coding and billing staff that process claims for lab testing should be aware of these codes and pricing. Show 9 New PLA CodesThe following PLA (type of service 5) codes are effective July 1, 2022 (implementation date July 5, 2022), and will be contractor priced until they are nationally priced: 0323U Infectious agent detection by nucleic acid (DNA and RNA), central nervous system pathogen, metagenomic next-generation sequencing, cerebrospinal fluid (CSF), identification of pathogenic bacteria, viruses, parasites, or fungi 0324U Oncology (ovarian), spheroid cell culture, 4-drug panel (carboplatin, doxorubicin, gemcitabine, paclitaxel), tumor chemotherapy response prediction for each drug 0325U Oncology (ovarian), spheroid cell culture, poly (ADP-ribose) polymerase (PARP) inhibitors (niraparib, olaparib, rucaparib, velparib), tumor response prediction for each drug 0326U Targeted genomic sequence analysis panel, solid organ neoplasm, cell-free circulating DNA analysis of 83 or more genes, interrogation for sequence variants, gene copy number amplifications, gene rearrangements, microsatellite instability and tumor mutational burden 0327U Fetal aneuploidy (trisomy 13, 18, and 21), DNA sequence analysis of selected regions using maternal plasma, algorithm reported as a risk score for each trisomy, includes sex reporting, if performed 0328U Drug assay, definitive, 120 or more drugs and metabolites, urine, quantitative liquid chromatography with tandem mass spectrometry (LC-MS/MS), includes specimen validity and algorithmic analysis describing drug or metabolite and presence or absence of risks for a significant patient-adverse event, per date of service 0329U Oncology (neoplasia), exome and transcriptome sequence analysis for sequence variants, gene copy number amplifications and deletions, gene rearrangements, icrosatellite instability and tumor mutational burden utilizing DNA and RNA from tumor with DNA from normal blood or saliva for subtraction, report of clinically significant mutation(s) with therapy associations 0330U Infectious agent detection by nucleic acid (DNA or RNA), vaginal pathogen panel, identification of 27 organisms, amplified probe technique, vaginal swab 0331U Oncology (hematolymphoid neoplasia), optical genome mapping for copy number alterations and gene rearrangements utilizing DNA from blood or bone marrow, report of clinically significant alternations Side Note: The CLFS data reporting requirement and application of the 15 percent phase-in reduction is not applicable in Calendar Years 2021 and 2022, in accordance with the Protecting Medicare and American Farmers from Sequester Cuts Act. Source: Centers for Medicare & Medicaid Services Transmittal 11398, May 4, 2022 Don’t Overlook These New PLA Codes was last modified: July 6th, 2022 by
Established by the American Medical Association (AMA) CPT® Editorial Panel, proprietary laboratory analyses PLA codes are alphanumeric CPT codes that provide corresponding descriptors for laboratories or manufacturers, to identify their test more specifically. Medical coding companies that process the claims for lab testing should be aware of these codes and pricing. A quarterly update for the Clinical Laboratory Fee Schedule (CLFS), issued May 4, includes nine new CPT® codes for proprietary laboratory analyses (PLAs). The types of PLA codes include Advanced Diagnostic Laboratory Tests (ADLTs) and Clinical Diagnostic Laboratory Tests (CDLTs) (defined under the Protecting Access to Medicare Act of 2014 (PAMA)). These analyses may include a range of medical laboratory tests including, but not limited to, Multianalyte Assays with Algorithmic Analyses (MAAA) and Genomic Sequencing Procedures (GSP). 9 New PLA Codes9 new PLA codes have been recently added to the list. These PLA (type of service 5) codes are effective July 1, 2022 (implementation date July 5, 2022), and will be contractor priced until they are nationally priced:
Coders have to note that when a PLA code is available to report a given proprietary laboratory service, same service should not be reported with any other CPT code(s) and other CPT code(s) should not be used to report services that may be reported with that specific PLA code. Some commercial payers and state Medicaid plans pay for some tests with PLA and MAAA codes. According to the Dark Intelligence Group, PLA and MAAA codes were intended to be used to identify new and more unusual tests than Medicare, Medicaid, and commercial insurers may have paid for previously. Increasing PLA denial rates is also a concern. When a physician orders a test with a PLA or an MAAA code, the lab will analyze the specimen and produce a result. If the claim doesn’t get paid, the lab has to manage the increased costs and appeal the denial. When it comes to PLA codes, many commercial payers require prior authorization to assess whether medical indications for the procedure were followed by looking at both the diagnosis and procedure codes. Most payers require that laboratories are restricted from obtaining clinical authorization on behalf of the ordering physician. If a laboratory service is performed without proper authorization, the service shall be denied and considered the financial liability of the laboratory. Professional insurance authorization services provided by experienced companies can ensure that all the procedures involved in the pre-cert process are managed efficiently. Read our expert PLA Medical Code blog. As a leading revenue cycle management organization, AIMA has expertise across all areas of the medical billing arena including coding and PLA applications. The American Medical Association approves PLA (Proprietary Laboratory Analyses) codes. These are alpha-numeric CPT codes with a corresponding descriptor for labs or manufacturers to identify their test specifically. With a lengthy and rigorous application process, on average, only 60 new codes are approved each quarter PLA codes are contained in a non-Category I subsection of the Pathology/Laboratory CPT codes. PLA Code section includes (but is not limited to) Advanced Diagnostic Laboratory Tests (ADLTs) and Clinical Diagnostic Laboratory Tests (CDLTs) as defined under the Protecting Access to Medicare Act of 2014 (PAMA). Tests assigned to PLA codes must meet specific criteria:
SCENARIOFor two decades, a leading European healthcare manufacturer developed an oncology test using pathway activity profiling within the specialty of breast, ovarian, bladder, colon, lung, prostate, and endometrium. Working with their US laboratory partner in Florida, AIMA provided consultation support to obtain a billable PLA code. The PLA application process is notoriously complex and laborious, taking several months from start to finish. Detailed knowledge of medical terminology, pathophysiology, pharmacology, and medical coding are all required to navigate the application intricacies. CHALLENGES
SOLUTIONAIMA assigned an in-house coding consultant to liaise directly with the laboratory and manufacturers, managing every aspect of their PLA application. Priority number one was to understand the test methodology. This was achieved by multiple conversations with the manufacturer and the senior lab team, and molecular genetics scientists. Furthermore, a thorough review was conducted of test publications. Referring to PUBLIC LAW 113–93—APR. 1, 2014, section 1834A under the Protecting Access to Medicare Act of 2014 (PAMA) and Federal Register Title 42 → Chapter IV → Subchapter B → Part 414 → Subpart G – Payment for Clinical Diagnostic Laboratory Tests to understand the proper definition of PLA. Next, we categorized the type of test and prepared the timeline of application. The project plan included a questionnaire based on our findings regarding necessary support documentation. Working with the lab, we helped to prepare a standard operating procedure (SOP) to meet the application requirements. The code descriptor, typical patient type, and procedure description were all prepared based on the test SOP. Our coding consultant conducted direct liaison and multiple discussions with the American Medical AssociationTechnical Advisory Group (TAG) committee. We were especially pleased to present to the committee on the test with all the supporting documentation. As a result, AIMA got the opportunity to participate in the 2021 annual AMA CPT editorial panel virtual meeting. RESULTShortly after the panel meeting, AIMA received confirmation that the PLA code application had been successfully approved and the new code officially published on July 1st, 2021. Consequently, PLA code 0262U is now available and can be billable by health insurance companies across the US effective Oct 2021.
If you are billing using PLA codes, here are some helpful guidelines:
Are you a laboratory wishing to apply for a new PLA code? AIMA has the experience, knowledge, and resources to help you to succeed. Contact our expert medical coding team today. |