Maximum Reimbursement Rates for Pathology Codes

Effective for dates of service on or after November 1, 2008, Medi-Cal policy indicates that laboratory services are paid at the least amount of the following:

• The amount billed
• The charge to the general public
• Medicare’s maximum allowance
• Medi-Cal’s maximum allowance

In some instances, California ChildrenÕs Services (CCS) and outpatient hospital claims for certain laboratory services receive a payment increase resulting in a rate that exceeds the Medicare maximum allowable amount. Current payments are limited to the Medicare maximum amount regardless of the modifier billed. On December 1, 2008, modifiers will be used when determining the appropriate Medicare maximum allowable amount for the procedure and/or modifier combination billed. Reimbursement for the professional component of such services will continue to receive the CCS supplemental increase when appropriate. Claims that are not split-billed will not be impacted.