Clinical Laboratory Fee Schedule

IMPORTANT UPDATE

CLFS Data Reporting Delayed

  • For Clinical Diagnostic Laboratory Tests (CDLTs) that are not Advanced Diagnostic Laboratory Tests (ADLTs), the data reporting is delayed by one year.  CDLT data that was supposed to be reported between January 1, 2020 and March 31, 2020, must now be reported between January 1, 2021, and March 31, 2021.  Labs must report data from the original data collection period of January 1, 2019 through June 30, 2019.  Data reporting for these tests will then resume on a three-year cycle, beginning in 2024. (Section 105(a)(1) of the  Further Consolidated Appropriations Act of 2020 (FCAA)).
  • In addition, the statutory phase-in provisions are updated.  For 2020, the rates for CDLTs that are not ADLTs or new CLDTs may not be reduced by more than 10% of the rates for 2019.  There will be a 15% reduction cap for each of 2021, 2022, and 2023.  (Section 105(a)(2) of FCAA).

CDLT Rates

Based on Reporting Period

Reduction Cap

2020

January 1, 2017 – May 30, 2017

10%

2021

January 1, 2017 – May 30, 2017

15%

2022

January 1, 2021 – March 31, 2021

15%

2023

January 1, 2021 – March 31, 2021

15%

 

Effective January 1, 2018, CLFS rates will be based on weighted median private payor rates as required by the Protecting Access to Medicare Act (PAMA) of 2014. For more details, visit PAMA Regulations. CMS held calls on the final rule and data reporting. For links to the slide presentations, audio recordings, and written transcripts, see CMS Sponsored Events.   

Fee Schedule Through December 31, 2017

Outpatient clinical laboratory services are paid based on a fee schedule in accordance with Section 1833(h) of the Social Security Act. Payment is the lesser of the amount billed, the local fee for a geographic area, or a national limit. In accordance with the statute, the national limits are set at a percent of the median of all local fee schedule amounts for each laboratory test code. Each year, fees are updated for inflation based on the percentage change in the Consumer Price Index. However, legislation by Congress can modify the update to the fees. Co-payments and deductibles do not apply to services paid under the Medicare clinical laboratory fee schedule.

Each year, new laboratory test codes are added to the clinical laboratory fee schedule and corresponding fees are developed in response to a public comment process. Also, for a cervical or vaginal smear test (pap smear), the fee cannot be less than a national minimum payment amount, initially established at $14.60 and updated each year for inflation.

Critical Access Hospitals

Critical access hospitals are generally paid for outpatient laboratory tests on a reasonable cost basis, instead of by the fee schedule, as long as the lab service is provided to a CAH outpatient.

Clinical Laboratory Center

For a one-stop resource webpage for Medicare Fee-for-Service (FFS) clinical laboratory providers and suppliers, visit the Clinical Laboratory Center.

Page Last Modified:
01/02/2020 03:05 PM