Clinical Diagnostic Laboratory Fee Schedule

40 - Clinical Diagnostic Laboratory Fee Schedule (Rev. 2643, Issued: 01-31-13, Effective: 07-01-13, Implementation: 07-01-13) The Medicare Claims Processing Manual, Chapter 16, “Laboratory Services From Independent Labs, Physicians, and Providers,” provides background and additional information for payment of laboratory services. Clinical diagnostic laboratory tests - whether performed in a physician’s office, by an independent laboratory, or by a hospital laboratory for its outpatients - are paid based on fee schedules. This section sets out rules for use of these schedules. The fee schedule amounts are adjusted annually to reflect changes in the Consumer Price Index (CPI) for all Urban Consumers (U.S. city average), or as otherwise specified by legislation. Adjustments are applied and amounts are determined by CMS and published for A/B MAC (A), (B), and (HHH) use and also on CMS Web site. A/B MACs (A), (B), and (HHH) are notified when and where updates are published. For a cervical or vaginal smear test (pap smear), payment is the lesser of the local fee or the national limitation amount, but not less than the national minimum payment amount. However, in no case may payment for these tests exceed actual charges. The Part B deductible and coinsurance do not apply. Regardless of whether a diagnostic laboratory test is performed in a physician’s office, by an independent laboratory, or by a hospital laboratory for its outpatients or nonpatients, it is considered a laboratory service. When a hospital laboratory performs diagnostic laboratory tests for nonhospital patients, the laboratory is functioning as an independent laboratory. National minimum limitation amounts are established each year for cervical or vaginal smear clinical laboratory tests. These payment amounts are published each year in a Recurring Update Notification issued by CMS. The affected CPT laboratory test codes for the national minimum payment amount are also identified in the annual Recurring Update Notification. National maximum limitation amounts may also be established for certain services and are also published each year this Recurring Update Notification. A/B MACs (A), (B), and (HHH) pay the lowest of the applicable current fee schedule, the actual charge, or the NLA. This applies to all clinical diagnostic laboratory tests except: • Laboratory tests furnished to a hospital inpatient whose stay is covered under Part A; • Laboratory tests performed by a Skilled Nursing Facility (SNF) for its own SNF inpatients and reimbursed under Part A or Part B and any laboratory tests furnished under arrangements to an SNF inpatient with Part A coverage. (The only covered source for laboratory services furnished under Part A is the SNF itself or a hospital with which the facility has a transfer agreement in effect.) • Laboratory tests furnished by hospital-based or independent ESRD dialysis facilities that are included under the ESRD composite rate payment; • Laboratory tests furnished by hospitals in States or areas which have been granted demonstration waivers of Medicare reimbursement principles for outpatient services. The State of Maryland has been granted such demonstration waivers; • Laboratory tests furnished to inpatients of a hospital with a waiver under §602(k) of the 1983 Amendments to the Act. This section of the Act provides that an outside supplier may bill under Part B for laboratory and other nonphysician services furnished to inpatients that are otherwise paid only though the hospital; • Laboratory tests furnished to patients of rural health clinics (RHCs) under an all inclusive rate; • Laboratory tests provided by a participating health maintenance organization (HMO) or health care prepayment plan (HCPP) to an enrolled member of the plan; and • Laboratory tests furnished by a hospice.