Clinical Labs Center
Temporary Delay in Implementing Ordering and Referring Denial Edits
Due to technical issues, implementation of the Phase 2 ordering and referring denial edits is being delayed. These edits would have checked the following claims for an approved or validly opted-out physician or non-physician who is an eligible specialty type with a valid individual National Provider Identifier (NPI). If either of these were missing or incorrect, claims would deny.
- Medicare Part B claims from laboratories, imaging centers and Durable Medical Equipment, Orthotics, and Supplies (DMEPOS) that have an ordering or referring physician/non-physician provider; and
- Part A Home Health Agency (HHA) claims that require an attending physician provider.
CMS will advise you of the new implementation date in the near future. In the interim, informational messages will continue to be sent for those claims that would have been denied had the edits been in place. For more information, see the revised article SE1305 – Full Implementation of Edits on the Ordering/Referring Providers in Medicare Part B, DME, and Part A Home Health Agency (HHA) Claims.
- New and Reconsidered Clinical Laboratory Fee Schedule (CLFS) Test Codes and Preliminary Payment Determinations for Calendar Year 2013
- New and Reconsidered Clinical Laboratory Fee Schedule Test Codes and Final Payment Determinations
- The CLIA Brochure [PDF, 455KB] is designed to provide education on CLIA test methods categorized, enrollment In the CLIA program, types of certificates, certificate compliance and performance measures, and certificate of accreditation.
- Extension of Reasonable Cost Payment for Clinical Lab Tests Performed by Hospitals with Fewer than 50 Beds in Qualified Rural Areas - On March 23, 2010, President Obama signed into law the Patient Protection and Affordable Care Act (PPACA). Section 3122 of the PPACA re-institutes reasonable cost payment for clinical lab tests performed by hospitals with fewer than 50 beds in qualified rural areas as part of their outpatient services for cost reporting periods beginning on or after July 1, 2010, through June 30, 2011. This could affect services performed as late as June 30, 2012. If you are a hospital who qualifies under Section 3122, you do not need to take any action. You will receive reasonable cost reimbursement for an entire year, starting with your cost reporting period beginning on or after July 1, 2010. Please be on the alert for more information pertaining to the PPACA.
Medicare FFS e-News Spotlights
Billing / Payment
- Clinical Laboratory Fee Schedule
- Electronic Billing & EDI Transactions - Medicare information on electronic transactions under HIPAA
- Medicare Coverage - General Information
- National Coverage Determinations (NCD) Manual - Pub. 100-03
- Lab NCDs
- Laboratory National Coverage Determinations (NCDs) Index - Opens in a new window
- Regulations and Notices
- Code of Federal Regulation Citations
- Negotiated Rulemaking: Coverage and Administrative Policies for Clinical Diagnostic Laboratory Services
- Pages 58788-58836 [PDF, 3MB]
- Pages 58837-58886 [PDF, 1MB]
- Pages 58887-58890 [PDF, 424KB]
- Medicare Claims Processing Manual - Chapter 16 - Laboratory Services [PDF, 403KB]
- Chapter 15 – Covered Medical and Other Health Services [PDF, 1MB]
- Quarterly Provider Updates
- Clinical Laboratory Improvement Amendments (CLIA)
- HIPAA - General Information
- Social Security Act: 1833(h)(1)(A) - Opens in a new window
- Social Security Act: 1833(h)(5)(A) - Opens in a new window
- Physician Self Referral
- National Correct Coding Initiative Edits
- Column 1/Column 2 Pathology and Laboratory Services - ccigrp10.zip - Opens in a new window
- Mutually Exclusive Pathology and Laboratory Services - megrp9.zip - Opens in a new window
- HCPCS - General Information
- Alpha-Numeric HCPCS
- Claim Adjustment Reason and Remittance Advice Remark Codes - Opens in a new window The latest HIPAA codes are available at the Washington Publishing Company (WPC) Website.
Medicare Secondary Payer
- Medicare Provider-Supplier Enrollment
- Enrollment Applications
- Conditions for Coverage (CfCs) & Conditions of Participations (CoPs)
- Information for Medicare Fee-for-Service Providers for the National Provider Identifier Standard (NPI)
- Quality Improvement Organizations (QIO)
- CMS Regional Offices
- Coordination of Benefits - General Information (COBC)
How to Stay Informed
Subscribe now to receive the weekly CMS Medicare FFS Provider e-News for the latest Fee-For-Service program information, event announcements, claims and pricer information, and MLN educational product updates.
- End-Stage Renal Disease and Clinical Laboratories Open Door Forum
- Press Releases - Opens in a new window CMS Media Release Search