AIMA’s expert medical coding team helps a laboratory successfully apply for a new PLA code for an oncology test now available and billable nationwide.
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:
- Firstly, they must be performed on human specimens.
- Secondly, they must be requested by the manufacturer or clinical laboratory that offers the test.
For 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.
- A detailed understanding of the technology and process related to the new test is required for the completion of the PLA application
- Knowledge of the compliance element of the test and the associate categories
- Collation of evidence to support the PLA code application criteria that specify the test should be commercially available in the US, not in Europe.
- Supporting information that providers and patients will get access to the test from the US.
AIMA 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.
Shortly 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.
“It was a great privilege to be instrumental in making this important new oncology test available to patients and providers across the US. Whist the PLA application process is complex, it is essential. Here at AIMA, we are especially proud to have the in-house expertise to oversee applications for our laboratory customers expertly. We ensure the process is seamless and skilfully managed to improve the likelihood of success.”Aaron Liston, AIMA CEO
If you are billing using PLA codes, here are some helpful guidelines:
- If a PLA code is available for a given service, that PLA code gains priority over the Category 1 CPT code.
- The service cannot be reported with any other CPT codes, nor can other CPT code(s) be used to report services that qualify for a specific PLA code.
- PLA codes can be given by either a single “sole source” laboratory or licensed or marketed to multiple providing laboratories, following the Food and Drug Administration’s (FDA) approval, by a manufacturer for a specific test.
- Reviewing these codes’ full, long descriptions is essential to determine the associated laboratory or manufacturer.
- The codes are updated quarterly, so check the AMA website for updates, including newly approved codes.