Other (Non-Medicare Fee Schedule) Lab Tests

Affected Providers

Physicians and non-physician practitioners who write prescriptions or orders for lab tests.

Background

According to the 2024 Medicare Fee-for-Service Supplemental Improper Payment Data, the improper payment rate for other (non-Medicare fee schedule) lab tests is 27.2%, with a projected improper payment amount of $1.3 billion.

Other (non-Medicare fee schedule) lab tests is a broad category of Medicare Part B services, which includes HCPCS codes for pathology and lab services. The category is Berenson-Eggers Type of Service (BETOS) Code category T1H lab tests — other (non-Medicare fee schedule). Examples of these services include urine drug screening, medication assays, genetic tests, tissue exams, blood tests, and others.

Denial Reasons

Insufficient documentation accounted for 87.7% of improper payments for other lab tests during the 2024 reporting period, while no documentation (5.1%), medical necessity (4.7%), and other errors (1.4%) also caused improper payments. “Other” errors include duplicate payment, non-covered or unallowable service, or ineligible Medicare patient errors.

Preventing Denials

You must meet specific requirements when ordering diagnostic lab tests.