Summary of Private Payor Rate-Based Medicare Clinical Laboratory Fee Schedule-Updated

A laboratory, including an independent laboratory, a physician office laboratory, or hospital outreach laboratory that meets the definition of an applicable laboratory under the Clinical Laboratory Fee Schedule (CLFS), must report information, including laboratory test HCPCS codes, associated private payor rates, and volume data. CMS recently updated resources:

• Summary (PDF): Overview of key terms and concepts, how to determine whether your laboratory is an applicable laboratory, and timeline
• FAQs (PDF): Responses to questions

Timeline:

• Collect data:  January 1-June 30, 2019
• Report data: January 1-March 31, 2022

The next data reporting period for CDLTs that are not ADLTs will be January 1, 2022 through March 31, 2022, and will be based on the original data collection period of January 1, 2019 through June 30, 2019. After this data reporting period, the three-year data reporting cycle for these tests will resume (that is, 2025, 2028, etc.).

The statutory phase-in of payment reductions resulting from private payor rate implementation is extended by an additional year, that is, through CY 2024. There is a 0.0 percent reduction for CY 2021 as compared to CY 2020, and payment may not be reduced by more than 15 percent for CYs 2022 through 2024 as compared to the prior year.

Source: https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/ClinicalLabFeeSched/Downloads/CY2019-CLFS-PrivatePayor-RateBased-Summary.pdf