Pathology/Lab Coding Alert

Now you have until May 31 to get the job done.

If you’re an “applicable lab” that has missed the deadline for reporting your lab-test price and volume data to CMS, you can breathe a sigh of relief.

That’s because the agency announced a 60-day delay in the reporting deadline set by the final rule for section 216(a) of the Protecting Access to Medicare Act (PAMA) of 2014. This rule requires CMS to calculate Medicare payment amounts for tests on the Clinical Laboratory Fee Schedule (CLFS) based on rates that private payers pay for the tests — which you, the “applicable laboratory” must report to CMS.

Confirm ‘Applicable Lab’ Status

Your National Provider Identifier (NPI) identifies your lab entity, and you’re an “applicable lab if you meet the following conditions:

• You receive more than half of your total Medicare revenue from CLFS and Physician Fee Schedule (PFS) payments
• You receive $12,500 or more under the CLFS during the data collection period (Jan. 1 and June 10, 2016).

If you’re uncertain, MLN Matters SE1619 walks you through four specific steps to determine if you’re an applicable lab that must report data.

Submit Data

As an applicable lab, you should have already registered with CMS to submit your lab’s data to Medicare. The registration process allows you access to the specific data collection system for CLFS, according to Sarah Harding, from the CMS Division of Ambulatory Services in a National Provider Call.

The data you need to report is for test volume and payment from each payer, which you received between Jan. 1 and June 10, 2016. CMS has moved the deadline for reporting this data from March 31 to May 31, 2017, but you should complete the task as soon as possible.

Remember: If your lab has more than one payment rate for the same private payer for the same test, or more than one payment rate for different payers for the same test, you must list each such payment rate and volume for the test at each such rate. The system will accept duplicate HCPCS codes within your submission, according to Ray Lee, CMS project manager for the development of CLFS reporting system in the National Provider Call.

Penalty: If you’re required to report data to Medicare and don’t, you could be subject to civil monetary penalties of up to $10,000 per day.

Understand Delay

According to CMS, the deadline extension to May 31 is intended to help labs that have requested additional time to review collected data, address any issues identified during such review, and compile the data into CMS’s required reporting format.

No more: Don’t expect another extension. CMS states that “This 60-day enforcement discretion period is the maximum amount of time CMS can permit to still have sufficient time to calculate the CLFS payment rates scheduled to go into effect on January 1, 2018.”

Resources: If you still have questions, contact the CLFS help desk at 844-876-0765 or clfshelpdesk@dcca.com. Or go to one of the following sites to read more:

• PAMA regulations webpage: www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/ClinicalLabFeeSched/PAMA-Regulations.html
• Deadline Delay announcement: www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/ClinicalLabFeeSched/Downloads/2017-March-Announcement.pdf
• National Provider Call: www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/ClinicalLab­FeeSched/CMS-Sponsored-Events.html
• MLN Matters on Applicable Labs: www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/Downloads/SE1619.pdf