Elimination of Maximum Daily Dollar Limits for Laboratory Services

Effective for dates of service (DOS) on or after January 1, 2013, the current maximum daily dollar limits for laboratory claims will be eliminated. Historically, Medicaid policy has enforced maximum daily dollar limits for laboratory services. Limits were established at $125 for independent laboratories. These limits applied to laboratory services rendered by the same provider, for the same beneficiary, on a single DOS. The purpose of the policy was to achieve annual savings to the Medicaid program by limiting unnecessary and excessive laboratory testing.  Current policy has been in place since September 1, 1987. Since that time, CMS has regulated laboratory testing through CLIA. Certification of laboratories was required. As a result, the certification process and subsequent monitoring of the labs by CMS has reduced the incentive to perform unneeded tests. In addition, through the Medical Service Administration’s (MSA) fraud and abuse measures, as well as the current Correct Coding Initiative (CCI) edits that place quantity limits on claims, MSA now has other methods to monitor appropriate billing.