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2008 Annual Update for Clinical Laboratory Fee Schedule and Laboratory Services Subject to Reasonable Charge Payment (LAB)
Posted January 9, 2008
MLN Matters Number: MM5813
Related Change Request (CR) #: 5813
Related CR Release Date: December 20, 2007
Effective Date: January 1, 2008
Related CR Transmittal #: R1400CP
Implementation Date: January 7, 2008
Understanding the Remittance Advice: A Guide for Medicare Providers, Physicians, Suppliers, and Billers serves as a resource on how to read and understand a Remittance Advice (RA). Inside the guide, you will find useful information on topics such as the types of RAs, the purpose of the RA, and the types of codes that appear on the RA. The RA Guide is available as a downloadable document from the Medicare Learning Network Publications Web page. To download and view, please go to www.cms.hhs.gov/MLNProducts/downloads/RA_Guide_Full_03-22-06.pdf on the Centers for Medicare & Medicaid Services (CMS) Web site.
Provider Types Affected
Clinical laboratories billing Medicare carriers, fiscal intermediaries (FIs), or Part A/B Medicare Administrative Contractors (A/B MACs).
What Providers Need to Know
This article and related Change Request (CR) 5813 contain important information regarding:
- The 2008 annual updates to the clinical laboratory fee schedule;
- Mapping for new codes for clinical laboratory tests; and
- Laboratory costs related to services subject to reasonable charge payments.
Key Points
Updates to Fees
In accordance with §1833(h)(2)(A)(i) of the Social Security Act (the Act), as amended by §628 of the Medicare Prescription Drug, Improvement, and Modernization Act (MMA) of 2003, the annual update to the local clinical laboratory fees for 2008 is 0 percent. Payment for a clinical laboratory test is the lesser of the actual charge billed for the test, the local fee, or the national limitation amount (NLA). For a cervical or vaginal smear test (pap smear), §1833(h)(7) of the Act requires payment to be the lesser of the local fee or the NLA, but not less than a national minimum payment amount.
Remember that the Part B deductible and coinsurance do not apply for services paid under the clinical laboratory fee schedule.
National Minimum Payment Amounts
The 2008 national minimum payment amount is $14.76 ($14.76 plus 0 percent update for 2008). The affected codes for the national minimum payment amount include the following:
88142
88154
G0123 |
88143
88164
G0143 |
88147
88165
G0144 |
88148
88166
G0145 |
88150
88167
G0147 |
88152
88174
G0148 |
88153
88175
P3000 |
National Limitation Amounts (Maximum)
For tests for which NLAs were established before January 1, 2001, the NLA is 74 percent of the median of the local fees. For tests for which NLAs are first established on or after January 1, 2001, the NLA is 100 percent of the median of the local fees in accordance with §1833(h)(4)(B)(viii) of the Act.
Access to 2008 Clinical Laboratory Fee Schedule
Internet access to the 2008 clinical laboratory fee schedule data file should be available after November 16, 2007, at www.cms.hhs.gov/ClinicalLabFeeSched on the Centers for Medicare & Medicaid Services (CMS) Web site.
Medicaid State agencies, the Indian Health Service, the United Mine Workers, Railroad Retirement Board, and other interested parties should use the Internet to retrieve the 2008 clinical laboratory fee schedule. It will be available in multiple formats: Excel, text, and comma delimited.
The 2008 clinical laboratory fee schedule is also available on the Upstate Medicare Division (UMD) Web site at www.umd.nycpic.com/clinicallab-fees.html.
Public Comments
On July 16, 2007, CMS hosted a public meeting to solicit input on the payment relationship between 2007 codes and new 2008 Current Procedural Terminology codes. Notice of the meeting was published in the Federal Register on May 25, 2007, and on the CMS Web site on June 18, 2007.
Recommendations were received from many attendees, including individuals representing laboratories, manufacturers, and medical societies. CMS posted a summary of the meeting and the tentative payment determinations at www.cms.hhs.gov/ClinicalLabFeeSched on the CMS Web site. Additional written comments from the public were accepted until October 5, 2007.
Comments after the release of the 2008 laboratory fee schedule can be submitted to the following address so that CMS may consider them for the development of the 2009 laboratory fee schedule. A comment should be in written format and include clinical, coding, and costing information. To make it possible for CMS and its contractors to meet a January 3, 2009, implementation date, comments must be submitted before August 1, 2008.
Centers for Medicare & Medicaid Services (CMS)
Center for Medicare Management
Division of Ambulatory Services
Mailstop: C4-02-14
7500 Security Boulevard
Baltimore, Maryland 21244-1850
Additional Pricing Information
The 2008 laboratory fee schedule includes separately payable fees for certain specimen collection methods (codes 36415, P9612, and P9615).
For dates of service January 1, 2008, through December 31, 2008, the fee for clinical laboratory travel code P9603 is $0.935 per mile and for code P9604 is $9.35 per flat rate trip basis. The clinical laboratory travel codes are billable only for traveling to perform a specimen collection for either a nursing home or homebound patient. If there is a revision to the standard mileage rate for calendar year 2008, CMS will issue a separate instruction on the clinical laboratory travel fees.
The 2008 laboratory fee schedule also includes codes that have a QW modifier to both identify codes and determine payment for tests performed by a laboratory registered with only a certificate of waiver under the Clinical Laboratory Improvement Amendments (CLIA).
Organ or Disease Oriented Panel Codes
Similar to prior years, the 2008 pricing amounts for certain organ or disease panel codes and evocative/suppression test codes were derived by summing the lower of the fee schedule amount or the NLA for each individual test code included in the panel code.
The CPT Editorial Panel has created code 80047 (Basic Metabolic Panel (Calcium, ionized)), which is an automated multi-channel chemistry (AMCC) code.
New code 80047 is not a replacement for code 80048 (Basic metabolic panel). Code 80047 is comprised of eight component test codes, i.e.:
- Calcium, ionized (82330);
- Carbon Dioxide (82374);
- Chloride (82435);
- Creatinine (82565);
- Glucose (82947);
- Potassium (84132);
- Sodium (84295); and
- Urea Nitrogen (BUN) (84520).
Note that 80047 cannot be billed for services ordered through an end stage renal disease (ESRD) facility. All tests billed for services ordered through an ESRD facility must be billed individually, not in an organ disease panel.
Mapping Information
CMS advises the following:
- New code 80047 is priced at the same rate as 80048 with final payment determined by the AMCC Panel Payment Algorithm;
- New code 82310QW is priced at the same rate as 82310;
- New code 82565QW is priced at the same rate as 82565;
- New code 82610 is priced at the same rate as 83883;
- New code 83655QW is priced at the same rate as 83655;
- New code 83993 is priced at the same rate as 83631;
- New code 84704 is priced at the same rate as 84702;
- New code 86356 is priced at the same rate as 86361;
- New code 87500 is priced at the same rate as 87641;
- New code 87809 is priced at the same rate as 87802;
- New code 89321QW is priced at the same rate as 89321;
- New code 89322 is priced at the sum of the rates of 89320 and 85007;
- New code 89331 is priced at the sum of the rates of 89320 and 87015; and
- New AMCC code ATP23 is priced at the same rate as ATP22.
Laboratory Costs Subject to Reasonable Charge Payment in 2008
For outpatients, the following codes are paid under a reasonable charge basis. In accordance with 42 CFR 405.502-405.508, the reasonable charge may not exceed the lowest of the actual charge or the customary or prevailing charge for the previous 12-month period ending June 30, updated by the inflation-indexed update. The inflation-indexed update is calculated using the change in the applicable Consumer Price Index for the 12-month period ending June 30 of each year as prescribed by §1842(b)(3) of the Act and 42 CFR 405.509(b)(1). The inflation-indexed update for year 2008 is 2.7 percent.
Manual instructions for determining the reasonable charge payment can be found in the Medicare Claims Processing Manual, Chapter 23, §§80-80.8. If there is insufficient charge data for a code, the instructions permit considering charges for other similar services and price lists. The Medicare Claims Processing Manual is located at www.cms.hhs.gov/Manuals/IOM/list.asp#TopOfPage on the CMS Web site.
When these services are performed for independent dialysis facility patients, the Medicare Claims Processing Manual, Chapter 8, §60.3 instructs that the reasonable charge basis applies. However, when these services are performed for hospital based renal dialysis facility patients, payment is made on a reasonable cost basis. Also, when these services are performed for hospital outpatients, payment is made under the hospital outpatient prospective payment system (OPPS).
Blood Products
P9010
P9021
P9035
P9044
P9055 |
P9011
P9022
P9036
P9048
P9056 |
P9012
P9023
P9037
P9050
P9057 |
P9016
P9031
P9038
P9051
P9058 |
P9017
P9032
P9039
P9052
P9059 |
P9019
P9033
P9040
P9053
P9060 |
P9020
P9034
P9043
P9054 |
Also, the following codes should be applied to the blood deductible as instructed in the Medicare General Information, Eligibility and Entitlement Manual, Chapter 3, §§20.5-20.54 (located at www.cms.hhs.gov/Manuals/IOM/list.asp#TopOfPage on the CMS Web site):
P9010
P9040 |
P9016
P9051 |
P9021
P9054 |
P9022
P9056 |
P9038
P9057 |
P9039
P9058 |
Note: Biologic products not paid on a cost or prospective payment basis are paid based on §1842(o) of the Act. The payment limits based on section 1842(o), including the payment limits for codes P9041, P9043, P9045, P9046, P9047, and P9048 should be obtained from the Medicare Part B Drug Pricing Files.
Transfusion Medicine
86850
86891
86920
86932
86972 |
86860
86900
86921
86945
86975 |
86870
86901
86922
86950
86976 |
86880
86903
86923
86960
86977 |
86885
86904
86927
86965
86978 |
86886
86905
86930
86970
86985 |
86890
86906
86931
86971
G0267 |
Reproductive Medicine Procedures
89250
89259
89281
89346 |
89251
89260
89290
89352 |
89253
89261
89291
89353 |
89254
89264
89335
89354 |
89255
89268
89342
89356 |
89257
89272
89343 |
89258
89280
89344 |
Additional Information
If you have questions, please contact your Medicare carrier, FI, or A/B MAC at their toll-free number, which can be found at www.cms.hhs.gov/MLNProducts/downloads/CallCenterTollNumDirectory.zip on the CMS Web site. For UMD, you can call the toll-free provider line at 877-567-7173.
To see the official instruction, CR 5813, issued to your Medicare FI, carrier, or A/B MAC, go to www.cms.hhs.gov/Transmittals/downloads/R1400CP.pdf on the CMS Web site.
Instruction for calculating reasonable charges are located in the Medicare Claims Processing Manual, Chapter 23, §§80-80.8 at www.cms.hhs.gov/manuals/downloads/clm104c23.pdf on the CMS Web site.
Disclaimer
This article was prepared as a service to the public and is not intended to grant rights or impose obligations. This article may contain references or links to statutes, regulations, or other policy materials. The information provided is only intended to be a general summary. It is not intended to take the place of either the written law or regulations. We encourage readers to review the specific statutes, regulations and other interpretive materials for a full and accurate statement of their contents.
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