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 Codes
9 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:
- 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
- 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
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.