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The devil is in the details.

Get the facts. Know her risk.

Frequently asked questions (FAQs) on reimbursement

Important information for healthcare professionals based in the U.S.

On August 1, 2012, several important updates related to health insurance coverage of high-risk HPV (hrHPV) tests were put into effect under the Affordable Care Act (ACA). Find out more below about reimbursement of the cobas®* HPV Test and women’s preventive services coverage through the ACA.

For the latest reimbursement information on the cobas® HPV Test, please contact the Roche Molecular Diagnostics reimbursement inquiry line at 1-866-805-9155.

 

cobas ® HPV Test

cobas® HPV Test Reimbursement

Q. What are the 2015 CPT®1 codes for reporting High Risk HPV testing?

A: The following 2015 CPT codes accurately report High Risk HPV testing:

CPT code 87624: Infectious agent detection by nucleic acid (DNA or RNA); Human Papillomavirus (HPV), high-risk types (eg, 16, 18, 31, 33, 35, 39, 45, 51, 52, 56, 58, 59, 68)

CPT code 87625: Infectious agent detection by nucleic acid (DNA or RNA); Human Papillomavirus (HPV), types 16 and 18 only, includes type 45, if performed

Q. What codes should be used to report the cobas®2 HPV Test?

A. The cobas HPV Test provides three results: High Risk Pool and specific genotype results only for types 16 and 18. Decisions about the specific codes to report are the responsibility of the lab.

Note: CMS established a code edit for the CPT codes 87624 and 87625 which allows the two codes to be billed together for the same Medicare patient on the same day if justified by the clinical circumstances. Non-Medicare (i.e., private) payers may or may not adopt this code edit.

Q. What does Medicare pay for the new CPT codes for High Risk HPV testing?

A. The 2015 Medicare payment rate for each of the new CPT codes for High Risk HPV testing for 2015 is $47.76. Non-Medicare (i.e., private) payer rates will vary.

Q. Why would labs choose the cobas® HPV Test?

A. The cobas HPV Test provides clinically important information in a more efficient manner by providing three results from one high risk screen as compared to any other available FDA- approved HPV test kits. Those results include providing a high risk pool result and specific genotype results for the highest risk genotypes, 16 and 18 only. Labs using the cobas HPV Test can provide more complete and valuable information to physicians and patients up front, without the need for reflex/additional testing.

Q. Where should I direct customers who have additional questions?

A. Roche Diagnostics Corporation maintains a unique-in-the-industry, in-house reimbursement email and hotline for our customers. Lab providers and other health care professionals may email inquiries to diagnostics.reimbursement@roche.com. Customers will receive a reply within one to two business days.



Note: This information is provided as a courtesy for informational purposes only and is not intended to be, and should not be interpreted as, reimbursement or billing advice. Health care professionals are responsible for determining appropriate reimbursement policies, including applicable CPT code assignment. Roche Diagnostics Corporation does not guarantee third-party coverage or payment for Roche products or provide remuneration to customers for claims that are denied by third-party payers.

 

1  CPT is a registered trademark of the American Medical Association (AMA)

2  COBAS is a trademark of Roche

Affordable Care Act (ACA)

Affordable Care Act (ACA) Coverage

Q. How does the ACA affect preventative services offered to women?

A. The ACA requires coverage with no cost sharing for certain preventive services for women by many private insurance plans. Those services include coverage for co-testing (Pap and hrHPV testing) for women ages 30-65 years.

Health insurance plans that took effect or were significantly changed after March 23, 2010 were required to provide free coverage for women’s preventive services beginning August 1, 2012.

The ACA applies to private health insurance plans and not to Medicare or Medicaid. Medicare law specifies the covered preventive services, which do not currently include HPV testing as a screen for cervical cancer.

Some plans are exempted from the ACA, such as grandfathered plans, so the provider should check with the patient's insurer for details. For more information on the ACA and a list of covered women’s preventative services, please visit the U.S. Department of Health and Human Services Women’s Preventative Services Guidelines.

Q. What does “no cost sharing” mean under the ACA?

A. No cost sharing means there should be no out-of-pocket expense or additional cost for these services to the patient. This includes co-payment, co-insurance, or a deductible.

Q. Some health insurance plans are not required to cover certain preventative services because they are “grandfathered” plans. What does that mean?

A. Under the ACA, health insurance plans that existed on or before March 23, 2010 are eligible for grandfathered status and would not have to meet all the requirements of the healthcare law, including the requirement to cover certain preventative services. But if an insurer or employer makes significant changes to a plan’s benefits or how much members pay through premiums, co-pays or deductibles, then the plan may lose its “grandfather” status.

Q. How many health insurance plans are exempt or “grandfathered” under the ACA?

A. The Kaiser Family Foundation survey of employer health benefits in 2012 found that 48 percent of individuals with healthcare coverage through their employer were in grandfathered plans.1 This number is declining over time and is down from 56 percent in 2011. For more information about grandfathered plans, visit Kaiser Health News.

Q. Does the ACA coverage align with the clinical screening guidelines for cervical cancer?

A. In 2012, U.S. clinical screening guidelines were harmonized across several medical societies. Guidelines from the ACS/ASCCP/ASCP, NCCN, and ACOG state that the preferred method for screening women ages 30-65 years is “co-testing” with Pap and hrHPV testing.2,3,4

In alignment with the guidelines, the ACA requires that health plans that took effect or were significantly changed after March 23, 2010 are required to provide free coverage of hrHPV testing for women 30 years and older.

 

Learn more about clinical screening guidelines.

  • Acronyms:

References:

1. Barr, S. FAQ: Grandfathered Health Plans. Kaiser Health News. December 16, 2012. http://www.kaiserhealthnews.org/stories/2012/december/17/grandfathered-plans-faq.aspx/. Accessed August 21, 2013.

2. Saslow, D.; et al, CA Cancer J Clin 2012;62:147-72

3. www.nccn.org/professionals/physician_gls/f_guidelines.asp#cervical_screening. Accessed January 2, 2013.

4. Screening for cervical cancer. Practice Bulletin No. 131. American College of Obstetricians and Gynecologists. Obstet Gynecol 2012;120:1222-38


Footnotes:

*COBAS is a trademark of Roche.      
†CPT copyright 2014 American Medical Association. All rights reserved. CPT is a registered trademark of the American Medical Association.


Disclaimer Copy:

Note: This information is provided as a courtesy for informational purposes only and is not intended to be, and should not be interpreted as, reimbursement or billing advice. Health care professionals are responsible for determining appropriate reimbursement policies, including applicable CPT code assignment. Roche Diagnostics Corporation does not guarantee third-party coverage or payment for Roche products or provide remuneration to customers for claims that are denied by third-party payers.