2018 Clinical Diagnostic Laboratory Fee Schedule-Final Determinations																																																														
"CPT codes, descriptions and other data only are copyright 2013 American Medical Association. All rights reserved. CPT is a registered trademark of the American Medical Association (AMA)."																																																														
HCPCS	"New National
Limit"		CA1	CA2	HI	NV	AK	ID	OR	WA	AZ	MT	ND	SD	UT	WY	CO	NM	OK	TX	IA	KS	KS	MO2	MO1	NE	IL	MN	WI	AR	LA	MS	IN	MI	FL	PR	AL	GA	TN	SC	VA	WV	NC	DE	DC	MD	NJ	PA	CT	NY2	NY1	NY3	ME	MA	NH	RI	VT	KY	OH	Short Descriptor	Contractor Provided Rationale	
			01112	01182	01212	01312	02102	02202	02302	02402	03102	03202	03302	03402	03502	03602	04112	04212	04312	04412	05102	05202	05202	05302	05302	05402	06102	06202	06302	07102	07202	07302	08102	08202	09102	09202	10102	10202	10302	11202	11302	11402	11502	12102	12202	12302	12402	12502	13102	13202	13282	13292	14112	14212	14312	14412	14512	15102	15202			
			LOC 00	LOC 00	LOC 00	LOC 00	LOC 00	LOC 00	LOC 00	LOC 00	LOC 00	LOC 00	LOC 01	LOC 02	LOC 00	LOC 00	LOC 00	LOC 00	LOC 00	LOC 00	LOC 00	LOC 12	LOC 15	LOC 07	LOC 15	LOC 00	LOC 00	LOC 00	LOC 00	LOC 00	LOC 00	LOC 00	LOC 00	LOC 00	LOC 00	LOC 20	LOC 00	LOC 00	LOC 00	LOC 00	LOC 00	LOC 00	LOC 00	LOC 00	LOC 00	LOC 00	LOC 00	LOC 00	LOC 00	LOC 00	LOC 00	LOC 00	LOC 00	LOC 00	LOC 00	LOC 00	LOC 00	LOC 00	LOC 00			
0001U	$720.00 		$720.00 	$720.00 	$720.00 	$720.00 	$720.00 	$720.00 	$720.00 	$720.00 	$720.00 	$720.00 	$720.00 	$720.00 	$720.00 	$720.00 	$452.60	$452.60	$452.60	$452.60	$720.00 	$720.00 	$720.00 	$720.00 	$720.00 	$720.00 	$452.60 	$452.60 	$452.60 	$452.60	$452.60	$452.60	$720.00 	$720.00 	$452.60	$452.60	$720.00 	$720.00 	$720.00 	$720.00 	$720.00 	$720.00 	$720.00 	$452.60	$452.60	$452.60	$452.60	$452.60	$452.60 	$452.60 	$452.60 	$452.60 	$452.60 	$452.60 	$452.60 	$452.60 	$452.60 	$720.00 	$720.00 	" Red blood cell antigen typing, DNA, "	Contractors looked at payment rates for similar tests on the CLFS (i.e. 81403) and also payment amounts derived from outside payer of the service.	
0002U	$25.00 		$25.00 	$25.00 	$25.00 	$25.00 	$25.00 	$25.00 	$25.00 	$25.00 	$25.00 	$25.00 	$25.00 	$25.00 	$25.00 	$25.00 	$200.00	$200.00	$200.00	$200.00	$25.00 	$25.00 	$25.00 	$25.00 	$25.00 	$25.00 	$200.00 	$200.00 	$200.00 	$200.00	$200.00	$200.00	$25.00 	$25.00 	$200.00	$200.00	$25.00 	$25.00 	$25.00 	$25.00 	$25.00 	$25.00 	$25.00 	$200.00	$200.00	$200.00	$200.00	$200.00	$200.00 	$200.00 	$200.00 	$200.00 	$200.00 	$200.00 	$200.00 	$200.00 	$200.00 	$25.00 	$25.00 	" Oncology (colorectal), quan assessment of 3 urine metabolites "	"Contractors used the cost per test as indicated by the company, minus the cost of shipping and sales/education and 18% discount already offer by the laboratory.  Other contractors based recommendation on similar urine assessment tests on the CLFS."	
0009U	$107.00 		$107.00 	$107.00 	$107.00 	$107.00 	$107.00 	$107.00 	$107.00 	$107.00 	$107.00 	$107.00 	$107.00 	$107.00 	$107.00 	$107.00 	$109.44	$109.44	$109.44	$109.44	$107.00 	$107.00 	$107.00 	$107.00 	$107.00 	$107.00 	$109.44 	$109.44 	$109.44 	$109.44	$109.44	$109.44	$107.00 	$107.00 	$109.44	$109.44	$107.00 	$107.00 	$107.00 	$107.00 	$107.00 	$107.00 	$107.00 	$109.44	$109.44	$109.44	$109.44	$109.44	$109.44 	$109.44 	$109.44 	$109.44 	$109.44 	$109.44 	$109.44 	$109.44 	$109.44 	$107.00 	$107.00 	" Oncology (breast cancer), ERBB2 (HER2) copy number by FISH "	Contractors used the payment amount based on HER2 FISH code 88367 as a similar test.  Some contractors adjusted the fee to reflect 2018 RVUs.	
0010U	$427.26 		$427.26 	$427.26 	$427.26 	$427.26 	$427.26 	$427.26 	$427.26 	$427.26 	$427.26 	$427.26 	$427.26 	$427.26 	$427.26 	$427.26 	$142.42	$142.42	$142.42	$142.42	$427.26 	$427.26 	$427.26 	$427.26 	$427.26 	$427.26 	$142.42	$142.42	$142.42	$142.42	$142.42	$142.42	$142.00 	$142.00 	$142.42	$142.42	$427.26 	$427.26 	$427.26 	$427.26 	$427.26 	$427.26 	$427.26 	$142.42	$142.42	$142.42	$142.42	$142.42	$142.42	$142.42	$142.42	$142.42	$142.42	$142.42	$142.42	$142.42	$142.42	$427.26 	$427.26 	" Infectious disease (bacterial), strain typing by WGS "	Some contractors used the payment amount of a similar test on the CLFS (87153) and adjusted the fee to reflect 2018 RVUs. Other contractors recommended code 87153 as a similar test but recommended a multiplier of 3.  	
0012U	"$2,515.60 "		"$2,515.60 "	"$2,515.60 "	"$2,515.60 "	"$2,515.60 "	"$2,515.60 "	"$2,515.60 "	"$2,515.60 "	"$2,515.60 "	"$2,515.60 "	"$2,515.60 "	"$2,515.60 "	"$2,515.60 "	"$2,515.60 "	"$2,515.60 "	$597.91	$597.91	$597.91	$597.91	"$2,515.60 "	"$2,515.60 "	"$2,515.60 "	"$2,515.60 "	"$2,515.60 "	"$2,515.60 "	$349.00 	$349.00 	$349.00 	$597.91	$597.91	$597.91	$349.00 	$349.00 	$597.91	$597.91	"$2,515.60 "	"$2,515.60 "	"$2,515.60 "	"$2,515.60 "	"$2,515.60 "	"$2,515.60 "	"$2,515.60 "	$597.91	$597.91	$597.91	$597.91	$597.91	$349.00 	$349.00 	$349.00 	$349.00 	$349.00 	$349.00 	$349.00 	$349.00 	$349.00 	"$2,515.60 "	"$2,515.60 "	" Germline disorders, gene rearrangement detection by WGS "	"Some contractors used payment rates of a similar test on the CLFS, code 81445.  Others used commercially available service rates of $349.00.  Other contractors used information from a similar code being gapfilled, 81425, to estimate a payment rate recommendation.  They reasoned that since 0012U  examines the whole genome, but only detects large scale mutations, the payment rate should be estimated at 81425 x 0.5."	
0013U	"$2,515.60 "		"$2,515.60 "	"$2,515.60 "	"$2,515.60 "	"$2,515.60 "	"$2,515.60 "	"$2,515.60 "	"$2,515.60 "	"$2,515.60 "	"$2,515.60 "	"$2,515.60 "	"$2,515.60 "	"$2,515.60 "	"$2,515.60 "	"$2,515.60 "	$597.91	$597.91	$597.91	$597.91	"$2,515.60 "	"$2,515.60 "	"$2,515.60 "	"$2,515.60 "	"$2,515.60 "	"$2,515.60 "	$597.91 	$597.91 	$597.91 	$597.91	$597.91	$597.91	$600.18 	$600.18 	$597.91	$597.91	"$2,515.60 "	"$2,515.60 "	"$2,515.60 "	"$2,515.60 "	"$2,515.60 "	"$2,515.60 "	"$2,515.60 "	$597.91	$597.91	$597.91	$597.91	$597.91	$597.91 	$597.91 	$597.91 	$597.91 	$597.91 	$597.91 	$597.91 	$597.91 	$597.91 	"$2,515.60 "	"$2,515.60 "	" Oncology (SO neoplasia), gene rearrangement detection by WGS "	"Some contractors used payment rates of a similar test on the CLFS, 81445.  Other contractors used information from a similar code being gapfilled, 81425, to estimate a payment rate recommendation.  They reasoned that since 0012U examines the whole genome, but only detects large scale mutations, the payment rate should be estimated at 81425 x 0.5. "	
0014U	"$2,515.60 "		"$2,515.60 "	"$2,515.60 "	"$2,515.60 "	"$2,515.60 "	"$2,515.60 "	"$2,515.60 "	"$2,515.60 "	"$2,515.60 "	"$2,515.60 "	"$2,515.60 "	"$2,515.60 "	"$2,515.60 "	"$2,515.60 "	"$2,515.60 "	$597.91	$597.91	$597.91	$597.91	"$2,515.60 "	"$2,515.60 "	"$2,515.60 "	"$2,515.60 "	"$2,515.60 "	"$2,515.60 "	$597.91 	$597.91 	$597.91 	$597.91	$597.91	$597.91	$600.18 	$600.18 	$597.91	$597.91	"$2,515.60 "	"$2,515.60 "	"$2,515.60 "	"$2,515.60 "	"$2,515.60 "	"$2,515.60 "	"$2,515.60 "	$597.91	$597.91	$597.91	$597.91	$597.91	$597.91 	$597.91 	$597.91 	$597.91 	$597.91 	$597.91 	$597.91 	$597.91 	$597.91 	"$2,515.60 "	"$2,515.60 "	" Hematology (hematolymphoid neoplasia), gene rearrangement detection by WGS "	"Some contractors used payment rates of a similar test on the CLFS, 81445.  Other contractors used information from a similar code being gapfilled, 81425, to estimate a payment rate recommendation.  They reasoned that since 0012U  examines the whole genome, but only detects large scale mutations, the payment rate should be estimated at 81425 x 0.5."	
81327	$192.00 		$192.00 	$192.00 	$192.00 	$192.00 	$192.00 	$192.00 	$192.00 	$192.00 	$192.00 	$192.00 	$192.00 	$192.00 	$192.00 	$192.00 	$158.48	$158.48	$158.48	$158.48	$192.00 	$192.00 	$192.00 	$192.00 	$192.00 	$192.00 	$158.48 	$158.48 	$158.48 	$158.48	$158.48	$158.48	$192.00 	$192.00 	$158.48	$158.48	$192.00 	$192.00 	$192.00 	$192.00 	$192.00 	$192.00 	$192.00 	$158.48	$158.48	$158.48	$158.48	$158.48	$158.48 	$158.48 	$158.48 	$158.48 	$158.48 	$158.48 	$158.48 	$158.48 	$158.48 	$24.50 	$24.50 	 SEPT9 (Septin9) methylation analysis 	"Contractors used the average of two similar tests on the CLFS.  Specifically, they used the payment amount provided by a laboratory for code 81287 and the commercially available payment amount provided by a laboratory for code 81288."	
81471	$914.00 		$914.00 	$914.00 	$914.00 	$914.00 	$914.00 	$914.00 	$914.00 	$914.00 	$914.00 	$914.00 	$914.00 	$914.00 	$914.00 	$914.00 	$495.95	$495.95	$495.95	$495.95	$914.00 	$914.00 	$914.00 	$914.00 	$914.00 	$914.00 	$495.95 	$495.95 	$495.95 	$495.95	$495.95	$495.95	$914.00 	$914.00 	$495.95	$495.95	$914.00 	$914.00 	$914.00 	$914.00 	$914.00 	$914.00 	$914.00 	$495.95	$495.95	$495.95	$495.95	$495.95	$495.95 	$495.95 	$495.95 	$495.95 	$495.95 	$495.95 	$495.95 	$495.95 	$495.95 	$914.00 	$914.00 	" X-linked intellectual disability dup/del, 60 Genes "	"Contractors used the average of the payment amount for a similar test on the CLFS, 81433, and the payment amount recommended by the laboratory. "	
81470	$914.00 		$914.00 	$914.00 	$914.00 	$914.00 	$914.00 	$914.00 	$914.00 	$914.00 	$914.00 	$914.00 	$914.00 	$914.00 	$914.00 	$914.00 	$755.96	$755.96	$755.96	$755.96	$914.00 	$914.00 	$914.00 	$914.00 	$914.00 	$914.00 	$755.96 	$755.96 	$755.96 	$755.96	$755.96	$755.96	$914.00 	$914.00 	$755.96	$755.96	$914.00 	$914.00 	$914.00 	$914.00 	$914.00 	$914.00 	$914.00 	$755.96	$755.96	$755.96	$755.96	$755.96	$755.96 	$755.96 	$755.96 	$755.96 	$755.96 	$755.96 	$755.96 	$755.96 	$755.96 	$914.00 	$914.00 	 X-linked intellectual disability (XLID) 60 Genes 	"Contractors used an average of the payment rate for a similar test on the CLFS, 81445, and a publically recommended payment amount.  "	
81551	"$2,030.00 "		"$2,030.00 "	"$2,030.00 "	"$2,030.00 "	"$2,030.00 "	"$2,030.00 "	"$2,030.00 "	"$2,030.00 "	"$2,030.00 "	"$2,030.00 "	"$2,030.00 "	"$2,030.00 "	"$2,030.00 "	"$2,030.00 "	"$2,030.00 "	"$2,102.42"	"$2,102.42"	"$2,102.42"	"$2,102.42"	"$2,030.00 "	"$2,030.00 "	"$2,030.00 "	"$2,030.00 "	"$2,030.00 "	"$2,030.00 "	2102.42	2102.42	2102.42	"$2,102.42"	"$2,102.42"	"$2,102.42"	"$2,030.00 "	"$2,030.00 "	"$2,102.42"	"$2,102.42"	"$2,030.00 "	"$2,030.00 "	"$2,030.00 "	"$2,030.00 "	"$2,030.00 "	"$2,030.00 "	"$2,030.00 "	"$2,102.42"	"$2,102.42"	"$2,102.42"	"$2,102.42"	"$2,102.42"	2102.42	2102.42	2102.42	2102.42	2102.42	2102.42	2102.42	2102.42	2102.42	"$2,030.00 "	"$2,030.00 "	" Oncology (prostate), profiling by real-time PCR of 3 genes "	Recommended payment rate based on company information and applied a 15% discount that was being offered by the provider.	
0004M	$79.00 		$79.00 	$79.00 	$79.00 	$79.00 	$79.00 	$79.00 	$79.00 	$79.00 	$79.00 	$79.00 	$79.00 	$79.00 	$79.00 	$79.00 	$79.00 	$79.00 	$79.00 	$79.00 	$79.00 	$79.00 	$79.00 	$79.00 	$79.00 	$79.00 	$79.00 	$79.00 	$79.00 	$79.00 	$79.00 	$79.00 	$79.00 	$79.00 	$79.00 	$79.00 	$79.00 	$79.00 	$79.00 	$79.00 	$79.00 	$79.00 	$79.00 	$79.00 	$79.00 	$79.00	$79.00	$79.00	$79.00 	$79.00 	$79.00 	$79.00 	$79.00 	$79.00 	$79.00 	$79.00 	$79.00 	$79.00 	$79.00 	 Scoliosis dna alys 	Contractors based payment rate recommendation on commercial lab charges.  Contractors further explained that resources required for this test are comparable or relevant from labs with similar tests.	
0006M	$150.00 		$150.00 	$150.00 	$150.00 	$150.00 	$150.00 	$150.00 	$150.00 	$150.00 	$150.00 	$150.00 	$150.00 	$150.00 	$150.00 	$150.00 	$150.00	$150.00	$150.00	$150.00	$150.00 	$150.00 	$150.00 	$150.00 	$150.00 	$150.00 	$150.00 	$150.00 	$150.00 	$150.00	$150.00	$150.00	$150.00 	$150.00 	$150.00	$150.00	$150.00 	$150.00 	$150.00 	$150.00 	$150.00 	$150.00 	$150.00 	$150.00	$150.00	$150.00	$150.00	$150.00	$150.00 	$150.00 	$150.00 	$150.00 	$150.00 	$150.00 	$150.00 	$150.00 	$150.00 	$150.00 	$150.00 	 Onc hep gene risk classifier 	Contractors based payment rate recommendation on commercial lab charges.  Contractors further explained that resources required for this test are comparable or relevant from labs with similar tests.	
0007M	$375.00 		$375.00 	$375.00 	$375.00 	$375.00 	$375.00 	$375.00 	$375.00 	$375.00 	$375.00 	$375.00 	$375.00 	$375.00 	$375.00 	$375.00 	$375.00	$375.00	$375.00	$375.00	$375.00 	$375.00 	$375.00 	$375.00 	$375.00 	$375.00 	$375.00 	$375.00 	$375.00 	$375.00	$375.00	$375.00	$375.00 	$375.00 	$375.00	$375.00	$375.00 	$375.00 	$375.00 	$375.00 	$375.00 	$375.00 	$375.00 	$375.00	$375.00	$375.00	$375.00	$375.00	$375.00 	$375.00 	$375.00 	$375.00 	$375.00 	$375.00 	$375.00 	$375.00 	$375.00 	$375.00 	$375.00 	 Onc gastro 51 gene nomogram 	Contractors used 50% of the publically available rate.  No data were received from the laboratory when requested.  	
0009M	$132.86 		$132.86 	$132.86 	$132.86 	$132.86 	$132.86 	$132.86 	$132.86 	$132.86 	$132.86 	$132.86 	$132.86 	$132.86 	$132.86 	$132.86 	$174.50	$174.50	$174.50	$174.50	$132.86 	$132.86 	$132.86 	$132.86 	$132.86 	$132.86 	$174.50 	$174.50 	$174.50 	$174.50	$174.50	$174.50	$132.86 	$132.86 	$174.50	$174.50	$132.86 	$132.86 	$132.86 	$132.86 	$132.86 	$132.86 	$132.86 	$174.50	$174.50	$174.50	$174.50	$174.50	$174.50 	$174.50 	$174.50 	$174.50 	$174.50 	$174.50 	$174.50 	$174.50 	$174.50 	$132.86 	$132.86 	 Fetal aneuploidy trisom risk 	Contractors used 50% of the publically available rate.  No data were received from the laboratory when requested.  	
81425	"$5,031.20 "		"$5,031.20 "	"$5,031.20 "	"$5,031.20 "	"$5,031.20 "	"$5,031.20 "	"$5,031.20 "	"$5,031.20 "	"$5,031.20 "	"$5,031.20 "	"$5,031.20 "	"$5,031.20 "	"$5,031.20 "	"$5,031.20 "	"$5,031.20 "	"$4,780.00"	"$4,780.00"	"$4,780.00"	"$4,780.00"	"$5,031.20 "	"$5,031.20 "	"$5,031.20 "	"$5,031.20 "	"$5,031.20 "	"$5,031.20 "	$349.00 	$349.00 	$349.00 	"$4,780.00"	"$4,780.00"	"$4,780.00"	"$5,031.20 "	"$5,031.20 "	"$4,780.00"	"$4,780.00"	"$5,031.20 "	"$5,031.20 "	"$5,031.20 "	"$5,031.20 "	"$5,031.20 "	"$5,031.20 "	"$5,031.20 "	"$4,780.00"	"$4,780.00"	"$4,780.00"	"$4,780.00"	"$4,780.00"	$349.00 	$349.00 	$349.00 	$349.00 	$349.00 	$349.00 	$349.00 	$349.00 	$349.00 	"$5,031.20 "	"$5,031.20 "	 Genome sequence analysis 	"Some contractors based initial recommendations on laboratories with similar test with charges of $349.00. Upon further review, however, several contractors revised their recommendations.  Some contractors looked to similar tests on the CLFS, specifically 81415, a Whole Exome Sequencing code, and adjusted the payment rate based on input from several laboratories.  Other contractors simply followed public recommendations to use CPT 81415 as a similar test on the CLFS to recommend a payment rate.   "	
81426	"$2,709.95 "		"$2,709.95 "	"$2,709.95 "	"$2,709.95 "	"$2,709.95 "	"$2,709.95 "	"$2,709.95 "	"$2,709.95 "	"$2,709.95 "	"$2,709.95 "	"$2,709.95 "	"$2,709.95 "	"$2,709.95 "	"$2,709.95 "	"$2,709.95 "	"$4,780.00"	"$4,780.00"	"$4,780.00"	"$4,780.00"	"$2,709.95 "	"$2,709.95 "	"$2,709.95 "	"$2,709.95 "	"$2,709.95 "	"$2,709.95 "	$349.00 	$349.00 	$349.00 	"$4,780.00"	"$4,780.00"	"$4,780.00"	"$2,709.95 "	"$2,709.95 "	"$4,780.00"	"$4,780.00"	"$2,709.95 "	"$2,709.95 "	"$2,709.95 "	"$2,709.95 "	"$2,709.95 "	"$2,709.95 "	"$2,709.95 "	"$4,780.00"	"$4,780.00"	"$4,780.00"	"$4,780.00"	"$4,780.00"	$349.00 	$349.00 	$349.00 	$349.00 	$349.00 	$349.00 	$349.00 	$349.00 	$349.00 	"$2,709.95 "	"$2,709.95 "	" Genome sequence analysis, each comparator genome "	"Some contractors based initial recommendations on laboratories with similar test with charges of $349.00. Upon further review, however, several contractors revised their recommendations.  Some contractors looked to similar tests on the CLFS, specifically 81415, a Whole Exome Sequencing code, and adjusted the payment rate based on input from several laboratories.  Other contractors simply followed public recommendations to use CPT 81415 as a similar test on the CLFS to recommend a payment rate.   "	
81427	"$2,337.65 "		"$2,337.65 "	"$2,337.65 "	"$2,337.65 "	"$2,337.65 "	"$2,337.65 "	"$2,337.65 "	"$2,337.65 "	"$2,337.65 "	"$2,337.65 "	"$2,337.65 "	"$2,337.65 "	"$2,337.65 "	"$2,337.65 "	"$2,337.65 "	$320.00	$320.00	$320.00	$320.00	"$2,337.65 "	"$2,337.65 "	"$2,337.65 "	"$2,337.65 "	"$2,337.65 "	"$2,337.65 "	$24.50 	$24.50 	$24.50 	$320.00	$320.00	$320.00	"$2,337.65 "	"$2,337.65 "	$320.00	$320.00	"$2,337.65 "	"$2,337.65 "	"$2,337.65 "	"$2,337.65 "	"$2,337.65 "	"$2,337.65 "	"$2,337.65 "	$320.00	$320.00	$320.00	$320.00	$320.00	$24.50 	$24.50 	$24.50 	$24.50 	$24.50 	$24.50 	$24.50 	$24.50 	$24.50 	"$2,337.65 "	"$2,337.65 "	 Genome re-evaluation 	"Initially, several contractors felt this code represented interpretation only and thus averaged two comparable codes (G0452-26 and 88291).  Upon further review, some contractors followed public recommendations to use CPT 81417 as a similar test on the CLFS. Others did not recommend this similar payment rate and instead estimated a professional labor rates for the code.   "	
