Pathology/Lab Coding Alert

Question: I’m trying to figure out if our lab has to report data about lab test price and usage to Medicare for PAMA. I’m basically familiar with the requirements, but how can I tell if it applies to my lab — and if it does, are there any tools available to help me comply?

Iowa Subscriber

Answer: Several resources are available to help you determine if your lab is an “applicable lab,” and if so, how you should report lab test data to Medicare to comply with the Protecting Access to Medicare Act (PAMA).

CMS Resources: You should check in with the CMS PAMA regulations page at www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/ClinicalLabFeeSched/PAMA-Regulations.html, which refers to several useful resources

One helpful link at this site is MLN Matters SE1619, which walks you through four specific steps to determine if you’re an applicable lab that must report data. If you figure out that you do need to report your data, SE1619 also provides a link to a list of applicable HCPCS codes that you need to monitor and report.

Another helpful tool available at the PAMA regulations page is MLN Matters SE1620, which provides a data reporting template 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.

Background: CMS published the final rule for implementing section 216 of PAMA in the June 23, 2016 Federal Register. Under PAMA, Medicare must determine payment rates for tests paid on the Clinical Laboratory Fee Schedule (CLFS) based on a weighted median of current market prices charged by applicable labs that report their data to Medicare. For a detailed description of the rule, refer to “PAMA Finalized: Get Ready for Lab Price Reporting — And CLFS Overhaul” in Pathology/Lab Coding Alert Vol 17 no 9.