November 8, 2002

2003 Clinical Laboratory Fee Schedule and Laboratory Services Subject to Reasonable Charge Payment Method

This program memorandum provides instructions for the calendar year 2003 clinical laboratory fee schedule, mapping for new codes for clinical laboratory tests and update for laboratory costs subject to the reasonable charge payment method.

PAP Smear Fees

Effective April 1st, Medicare establishes national payment limitations (NLAs) for 12 Cytopathology codes that were previously paid on a gap-filled basis. The pap smear procedures will be capped at 100% of the national median. All other laboratory tests on the Medicare fee schedule remain capped at 74% of the national median.

The Health Care Financing Administration (CMS) calculated National Limitation Amounts for the vaginal and cervical smear tests and provided carriers with the following 2001 Clinical Lab Fee Schedule Amounts

G0123 $28.00 G0143 28.00 G0144 28.00 G0145 28.00 G0147 15.73 G0148 18.85 88142 28.00 88143 28.00 88144 28.00 88145 28.00 88147 14.60 88148 18.85

In addition to these new fees, CMS provided revised fees for the following Clinical Lab Fee Schedule procedure codes:

G0107 $4.49 82270 $4.49 82273 $4.49 82273QW $4.49 86683 $4.49

The above fees are effective for claims processed on and after April 2, 2001, for dates of service on and after January 1, 2001. No adjustments will be made to previously processed claims.

See CMS Program Memorandum AB-01-42 for complete document: http://www.cms.gov/manuals/pm_trans/AB0142.pdf

2001 Clinical Laboratory Fee Schedule and Laboratory Costs Subject to Reasonable Charge Payment Methodology

• No annual update (economic index) to the local laboratory fees for 2001
• NLA (National Limitation Amount) calculation for 2001 remains at 74 percent of the median.
• The 3 month grace period for deleted codes is defined in the Medicare Carriers Manual section 4509.3 and begins January 1, 2001.
• 2001 Fee Schedule includes codes that have a "QW" modifier for laboratory services granted waived status under CLIA standards
• PSA code 84152 (complexed direct measurement) requires an instrument analysis of the result for billing.
• Tumor Marker Tests: New CPT codes 86294, 86300, 86301, 86304 and revised code 86316 provide more specificity.
• Microbiology Culture Testing (codes 87040 - 87163) contain complex coding changes
• Urea Breath Testing. Codes 83013 and 83014 are to be utilized for billing breath tests performed using the Carbon 13 isotope method. Code 83014 was established to report the drug administration and sample collection. Code 83013 reflects the breath test analysis.
• Helicobacter Pylori - new CPT 87339 for enzyme immunoassay
• Microbial Identification Test kits - When billing for all three organisms [Candida (code 87480), Gardnerella (code 87510) and Trichomonas (code 87797)], using one specimen for the test kit regardless of the number of medically necessary tests performed - payment should reflect one unit of service using code 87797 and should not be billed individually.
• Organ or Disease Oriented Panels - The pricing amount for each organ or disease panel was derived by summing the lower of the fee schedule or the NLA for each individual test included in the panel. The local fee amount field and the NLA field on the data file will be zero-filled.
• Cervical or Vaginal Smear Tests - Carriers will continue to gap fill codes 88142, 88143, 88144, 88145, 88147 and 88148 and G0123, G0143, G0144, G0145, G0147, G0148.
• HIV Resistance Testing - New codes 87901 for genotype and 87903 and 87904 for phenotype testing have been created for HIV type 1.
  • Regardless of the number of drugs analyzed, the new codes for phenotype testing reflect testing for up to only 15 drugs and additional drug testing is not separately payable.
  • Section 1862 (a) (4) of the Act codified at section 42 CFR 411.9 does not permit Medicare to pay for laboratory testing performed outside of the United States, except for very limited circumstances.
  • Most genotype and phenotype testing is being performed under the "home-brew" status and therefore are not subject to FDA approval.
  • Reasonable prices can be established for the new codes using the addition of codes 87252, 87253, 83890, 83894,83904.
  • The new more specific codes represent both the performance of the test and interpretation and reporting the results so that codes representing the test components (e.g. 87252, 87253, 83890, 83894, 83898, 83902, 83912) may not be submitted in lieu or addition to the new codes 87901, 87903, and 87904.

  See the following CMS Program Memorandum AB-00-109 for instructions to the Intermediaries and Carriers for the implementation of the 2001 clinical laboratory fee schedule and mapping for year 2001 CPT codes for clinical diagnostics laboratory tests. http://www.cms.gov/manuals/pm_trans/AB00109.pdf

Clinical Laboratory Fees On-Line

NHIC - California

2001 www.medicarenhic.com (Pricing updates, clinical laboratory)

2000 ICD Codes

Now is the time to purchase your 2001 Edition ICD-9-CM coding manual! Several revisions have recently been made to ICD-9-CM codes for calendar year 2001.

It is your responsibility to ensure that the most current ICD-9-CM code is used when billing Medicare for services. This includes revised codes and billing codes to their highest specificity.

ICD-9-CM code revisions, found in the 2001 ICD-9-CM coding manual, are effective for claims received on or after October 1, 2000. Carriers will allow a 90-day grace period, during which Carriers will accept both old and new ICD-9-CM codes. This 90-day grace period expires January 1, 2001. Therefore, you must begin using ICD-9-CM codes found in your 2001 Edition ICD-9-CM manual for claims received on or after January 1, 2001. Claims billed on or after January 1, 2001 with outdated ICD-9-CM codes will be denied.