Pathology/Lab Coding Alert

Understand applicable labs, ADLTs, and more.

If your head is still swimming with the whole idea of repricing the Clinical Laboratory Fee Schedule under the Protecting Access to Medicare Act (PAMA), you’re not alone. Read on to see what some other readers are asking, and what our experts have to say about it.

Q: What is the key CMS resource to use if I have questions about my lab’s compliance with the Protecting Access to Medicare Act (PAMA) Section 216 that requires reporting private payer rate and volume data?

A: The PAMA regulations page is your one-stop shop for current info on what you need to do to comply with the law. You’ll find it at www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/ClinicalLabFeeSched/PAMA-Regulations.html. Here you’ll find the Excel data template, EIDM user guide, relevant MedLearn Matters articles, help desk links. Plus, this site hosts all the info referenced in the remaining Q/As.

Q: How do I know if we’re an “applicable lab” that must report data beginning in January?

A: MLN Matters SE1619 walks you through four specific steps to determine if you’re an applicable lab that must report data. But the short answer is that 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).

Q: Do we have to report data for all lab tests for CDLT pricing, and if not, how do we know which tests?

A: You do not have to report data for every lab test to CMS as part of the PAMA repricing of Clinical Diagnostic Laboratory Tests (CDLTs). The PAMA regulations page includes a link to an Excel file listing » » the HCPCS (CPT® and Level II codes) that you’ll need to report using the Fee for Service Data Collection System (FFSDCS).

Under the final rule, a certain class of lab tests will undergo a different procedure to establish pricing. Those are “advanced diagnostic laboratory tests,” or ADLTs

When CMS needs to set the price for a new or substantially revised test, or when no private payer data is available for an existing test, CMS will use crosswalking or gapfilling methodologies to establish payment, said Craig Dobyski, from the CMS Division of Ambulatory Services during a recent provider call to explain the PAMA final rule.

Q: How do I actually go about reporting the data to Medicare?

A: MLN Matters SE1620 provides a data reporting template and instructions to help you format the data you gather to submit to Medicare. You may populate the template through system-generated content or manually via an online interface.