CMS Confirms 49% Cut to BRCA CPT Code

By Bio-IT World Staff

December 30, 2013 | On Friday, the Centers for Medicare and Medicaid Services confirmed a 49% cut to CPT code 81211, which covers reimbursement for BRCA 1&2 gene tests.

On September 30, CMS posted a National Limitation Amount (NLA) for code 81211 of $2,700. On November 29, CMS revised the NLA to $1,438.14. The NLA for 81211 was based on the median of Medicare Administrative Contractors-submitted prices, CMS said, and will be effective for tests performed on or after January 1, 2014, though the pricing cut is subject to a comment period though January 27, 2014 and any changes will be effective prospectively from April 1, 2014.

Prior to the Supreme Court case this summer, only Myriad Genetics offered testing for BRCA 1&2. Now other laboratories can offer testing, and Medicare Administrative Contractors submitted their NLA recommendation based on pricing offered by these additional laboratories.

“At present, it is our understanding laboratories are offering the CPT code 81211 test for prices that range from approximately $900 to $2900,” CMS said in their reconsideration period notification.

Goldman Sachs analysts flagged the news as negative for Myriad, but acknowledged a lack of visibility into the pace and magnitude of cuts from private payers, which would impact the severity of the changes to Myriad’s business.