Provider Types Affected Clinical laboratories billing Medicare carriers, intermediaries, or Part A/B Medicare Administrative Contractors (A/B MACs) Provider Action Needed This article and related CR5362 contain important information regarding:
It is important that affected laboratories understand these changes to ensure correct and accurate payments from Medicare. Key Points Update to Fees In accordance with §1833(h)(2)(A)(i) of the Social Security Act (the Act), as amended by Section 628 of the Medicare Prescription Drug, Improvement, and Modernization Act (MMA) of 2003, the annual update to the local clinical laboratory fees for 2007 is zero (0) percent. Section 1833(a)(1)(D) of the Act provides that payment for a clinical laboratory test is the lesser of the actual charge billed for the test, the local fee, or the National Limitation Amount (NLA). The Part B deductible and coinsurance do not apply for services paid under the clinical laboratory fee schedule. National Minimum Payment Amounts For a cervical or vaginal smear test (Pap smear), §1833(h)(7) of the Act requires payment to be the lesser of the local fee or the NLA, but not less than a national minimum payment amount. Also, payment may not exceed the actual charge. The 2007 national minimum payment amount is $14.76 ($14.76 plus zero percent update for 2007). The affected codes for the national minimum payment amount include the following Current Procedure Terminology (CPT) codes:
National Limitation Amounts (Maximum) For tests for which NLAs were established before January 1, 2001, the NLA is 74 percent of the median of the local fees. For tests for which NLAs are first established on or after January 1, 2001, the NLA is 100 percent of the median of the local fees in accordance with §1833(h)(4)(B)(viii) of the Act. Access to 2007 Clinical Laboratory Fee Schedule Internet access to the 2007 clinical laboratory fee schedule data file should be available after November 20, 2006, at http://www.cms.hhs.gov/ClinicalLabFeeSched Medicaid State agencies, the Indian Health Service, the United Mine Workers, Railroad Retirement Board, and other interested parties should use the Internet to retrieve the 2007 clinical laboratory fee schedule. It will be available in multiple formats: Excel, text, and comma delimited. Public Comments On July 17, 2006, CMS hosted a public meeting to solicit input on the payment relationship between 2006 codes and new 2007 Current Procedural Terminology codes. Notice of the meeting was published in the Federal Registeron May 26, 2006 and on the CMS Web site on June 19, 2006. Recommendations were received from many attendees, including individuals representing laboratories, manufacturers, and medical societies. CMS posted a summary of the meeting and the tentative payment determinations on the Web site http://www.cms.hhs.gov/ClinicalLabFeeSched . Additional written comments from the public were accepted until September 26, 2006. Additional Pricing Information The 2006 laboratory fee schedule includes separately payable fees for certain specimen collection methods (codes 36415, P9612, and P9615). For dates of service January 1, 2007 through December 2007, the fee for clinical laboratory travel code P9603 is $0.935 per mile and for code P9604 is $9.35 per flat rate trip basis. The clinical laboratory travel codes are billable only for traveling to perform a specimen collection for either a nursing home or homebound patient. The standard mileage rate for transportation costs was increased by the Federal Government’s Treasury Department to 48.5 cents a mile and this amount is incorporated into the fees for travel codes P9603 and P9604. The 2007 laboratory fee schedule also includes codes that have a “QW” modifier to both identify codes and determine payment for tests performed by a laboratory registered with only a certificate of waiver under the Clinical Laboratory Improvement Amendments (CLIA). Based on comments and data submitted, codes 83037 and 83037QW are priced by crosswalking to code 82985. Organ or Disease Oriented Panel Codes Similar to prior years, the 2006 pricing amounts for certain organ or disease panel codes and evocative/suppression test codes were determined by Medicare by summing the lower of the fee schedule amount or the NLA for each individual test code included in the panel code. Mapping Information CMS advises the following:
Laboratory Costs Subject to Reasonable Charge Payment in 2006 For outpatients, the following codes are paid under a reasonable charge basis. In accordance with 42 CFR 405.502 – 405.508, the reasonable charge may not exceed the lowest of the actual charge or the customary or prevailing charge for the previous 12-month period ending June 30, updated by the inflation-indexed update. The inflation-indexed update is calculated using the change in the applicable Consumer Price Index for the 12-month period ending June 30 of each year as prescribed by §1842(b)(3) of the Act and 42 CFR 405.509(b)(1). The inflation-indexed update for year 2007 is 4.3 percent. Manual instructions for determining the reasonable charge payment can be found in the Medicare Claims Processing Manual , Chapter 23, §80-80.8. If there is insufficient charge data for a code, the instructions permit considering charges for other similar services and price lists. The Medicare Claims Processing Manual, is located at http://www.cms.hhs.gov/Manuals/IOM/list.asp#TopOfPage When these services are performed for independent dialysis facility patients, Medicare Claims Processing Manual , Chapter 8, §60.3 instructs the reasonable charge basis applies. However, when these services are performed for hospital based renal dialysis facility patients, payment is made on a reasonable cost basis. Also, when these services are performed for hospital outpatients, payment is made under the hospital outpatient prospective payment system (OPPS). Blood Products
Also, the following codes should be applied to the blood deductible, as instructed in the Medicare General Information, Eligibility and Entitlement Manual , (also available at http://www.cms.hhs.gov/Manuals/IOM/list.asp#TopOfPage
NOTE: Biologic products not paid on a cost or prospective payment basis are paid based on §1842(o) of the Act. The payment limits based on section 1842(o), including the payment limits for codes P9041, P9043, P9045, P9046, P9047, and P9048, should be obtained from the Medicare Part B Drug Pricing Files. Transfusion Medicine
Reproductive Medicine Procedures
Additional Information If you have questions, please contact your Medicare fiscal intermediary (FI), carrier, or A/B MAC at their toll-free number which may be found at: http://www.cms.hhs.gov/MLNProducts/downloads/CallCenterTollNumDirectory.zip For complete details regarding CR5362, please see the official instruction issued to your Medicare FI, carrier, or A/B MAC. That instruction may be viewed by going to http://www.cms.hhs.gov/Transmittals/downloads/R1122CP.pdf Instructions for calculating reasonable charges are located in the Medicare Claims Processing Manual (Pub. 100-04) Chapter 23, Sections 80-80.8 at http://www.cms.hhs.gov/manuals/downloads/clm104c23.pdf Disclaimer MLN Matters Number: MM5362 Flu Shot Reminder – As a respected source of health care information, patients trust their doctors’ recommendations. If you have Medicare patients who haven’t yet received their flu shot, help protect them by recommending an annual influenza and a one time pneumococcal vaccination. Medicare provides coverage for flu and pneumococcal vaccines and their administration. – And don’t forget to immunize yourself and your staff. Protect yourself, your patients, and your family and friends. Get Your Flu Shot. Remember - Influenza vaccination is a covered Part B benefit. Note that influenza vaccine is NOT a Part D covered drug. For more information about Medicare’s coverage of adult immunizations and educational resources, go to CMS’s Web site: http://www.cms.hhs.gov/MLNMattersArticles/downloads/SE0667.pdf Posted: 12/13/2006 CPT codes, descriptions, and other data only are copyright 2006 American Medical Association (or such other date of publication of CPT). All Rights Reserved. Applicable FARS/DFARS Apply.
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on the Centers for Medicare & Medicaid Services (CMS) Web site. 
on the CMS Web site.
on the CMS Web site.
