Medicare Payment for Part B Laboratory Services

Resources 

Clinical laboratory testing constitutes less than two percent of all Medicare spending, yet reimbursement for these essential services has been subject to significant freezes and cuts over the last 25 years. Cuts to the Part B CLFS have serious consequences for community and regional laboratories that cannot be absorbed without affecting patient access to health care services.

The overhaul of the Medicare clinical laboratory payment system initiated by the Protecting Access to Medicare Act (PAMA) continues a stream of previous cuts to Part B CLFS payment rates, including:

  • Five consecutive 1.75 percent direct reductions from 2010-2014 under the Affordable Care Act;
  • A productivity adjustment every year under the Affordable Care Act;
  • A 2 percent reduction from the Middle Class Tax Relief and Job Creation Act of 2012 (SGR patch); and
  • A 2 percent reduction beginning in FY 2013 and ongoing from the Budget Control Act of 2011 (sequestration).

Across-the-board cuts to the Clinical Laboratory Fee Schedule do not modernize the CLFS. These reductions devastate the ability of community and regional laboratories to continue to serve their communities and provide cost effective care to chronic populations, including homebound and skilled nursing facility residents.

As demonstrated in a 2012 survey conducted by the George Washington University, a significant number of community clinical laboratories operate on very low margins that do not exceed 3 percent. Cumulative cuts in reimbursement that exceed these margins threaten the survival of many community laboratories. If community-based laboratories leave the market as a result, many physicians and patients will not have timely access to these important diagnostic tools.

Click here to view a map of where NILA’s member laboratories are located.

 

Resources

MLN Matters, January 13, 2017

Changes to the Laboratory National Coverage Determinations (NCD) Edit Software for April 2017. View/download PDF
MLN Matters, December 22, 2016
Medicare Billing: 837P and Form CMS-1500 Fact Sheet — Revised
A revised
Medicare Billing: 837P and Form CMS-1500 Fact Sheet is available. Learn about:
  • Medicare institutional claims submission and coding
  • When Medicare will accept a hard copy claim form
  • Timely filing
 
ICD-9-CM, ICD-10-CM, ICD-10-PCS, CPT, and HCPCS Code Sets Educational Tool — Revised
A revised
ICD-9-CM, ICD-10-CM, ICD-10-PCS, CPT, and HCPCS Code Sets Educational Tool is available. Learn about the code sets and payment information.
 

On October 5, 2016, OIG Releases Reports on Medicare Payments for Lab Tests in 2015; Update on CMS’s Progress on Changing How Medicare Pays for Lab Tests

 

On October 26, 2015, NILA Comments On 2016 Clinical Laboratory Fee Schedule (CLFS) Coding and Pricing Determination For Toxicology Testing.   

CMS CLFS Homepage
Access CLFS data files, regulatory notices, and announcements about public meetings

Manual System: CY 2015 Annual Update for CLFS and Laboratory Services Subject to Reasonable Charge Payment