Clinical Diagnostic Laboratory Fee Schedule

$179 / year

This dataset contains the clinical diagnostic laboratory fee schedule revised for January 2016. The update includes all changes identified in Change Request (CR) 9465.

Complexity

Outpatient clinical laboratory services are paid based on a fee schedule in accordance with Section 1833(h) of the Social Security Act. Payment is the lesser of the amount billed, the local fee for a geographic area, or a national limit. In accordance with the statute, the national limits are set at a percent of the median of all local fee schedule amounts for each laboratory test code. Each year, fees are updated for inflation based on the percentage change in the Consumer Price Index. However, legislation by Congress can modify the update to the fees. Co-payments and deductibles do not apply to services paid under the Medicare clinical laboratory fee schedule.

Each year, new laboratory test codes are added to the clinical laboratory fee schedule and corresponding fees are developed in response to a public comment process. Also, for a cervical or vaginal smear test (pap smear), the fee cannot be less than a national minimum payment amount, initially established at $14.60 and updated each year for inflation.

Critical access hospitals are paid for outpatient laboratory tests on a reasonable cost basis, instead of by the fee schedule. Hospitals with fewer than 50 beds in qualified rural areas—those with population densities in the lowest quartile of all rural areas—are paid based on a reasonable cost basis for outpatient clinical laboratory tests for cost reporting periods between July 2004 and July 2006.

Note: Where modifier is shown in the dataset, QW denotes a CLIA waiver test.The QW modifier states that the tests you are performing are “simple laboratory examinations and procedures that have an insignificant risk of an erroneous result”. They are considered “CLIA waived” and therefore require a “CLIA Certificate of Waiver”.

Date Created

2015-12-15

Last Modified

2020-01-27

Version

2020-01-27

Update Frequency

Annual

Temporal Coverage

2020

Spatial Coverage

United States

Source

John Snow Labs; Centers for Medicare and Medicaid Services;

Source License URL

Source License Requirements

N/A

Source Citation

N/A

Keywords

Medicare Schedule, Diagnostic Laboratory Fee Schedule, Outpatient Clinical Laboratory Services, Outpatient Laboratory Services, Medicare Clinical Laboratory Fee Schedule, Critical Access Hospitals, Blood Laboratories, Medicare Laboratory Schedule, Clinical Laboratories, Diagnostic Laboratories

Other Titles

Blood Lab Clinical Diagnostic Laboratory Fee Schedule, Medicare Schedule Clinical Diagnostic Laboratory Fee Schedule, Clinical Laboratory Diagnostic Fee Schedule

NameDescriptionTypeConstraints
YearCalender year associated with the CLFS (Clinical Laboratory Fee Schedule).number-
QuarterQuarter associated with the CLFS (Clinical Laboratory Fee Schedule).string-
HCPCS_CodeHCPCS, The Healthcare Common Procedure Coding System, includes All current year active CPT and alpha-numeric codes subject to the Clinical Laboratory Fee Schedule.stringrequired : 1
Description_of_HCPCS_CodeShort description of HCPCS Codestringrequired : 1
Is_QW_ModifierWhere modifier is shown, QW denotes a CLIA waiver test. The QW modifier states that the tests you are performing are "simple laboratory examinations and procedures that have an insignificant risk of an erroneous result". They are considered "CLIA waived" and therefore require a "CLIA Certificate of Waiver".boolean-
IndicatorIndicates whether it is National or local pricing indicatorstringrequired : 1
Payment_RateIndicates the payment amount associated with each HCPCS code.numberlevel : Ratio
YearQuarterHCPCS CodeDescription of HCPCS CodeIs QW ModifierIndicatorPayment Rate
2020Q10001URbc dna hea 35 ag 11 bld grpFalseNational720.0
2020Q10002MLiver dis 10 assays w/ashFalseNational503.4
2020Q10002UOnc clrct 3 ur metab alg plpFalseNational25.0
2020Q10003MLiver dis 10 assays w/nashFalseNational503.4
2020Q10003UOnc ovar 5 prtn ser alg scorFalseNational950.0
2020Q10004MScoliosis dna alysFalseNational79.0
2020Q10005UOnco prst8 3 gene ur algFalseNational760.0
2020Q10006MOnc hep gene risk classifierFalseNational150.0
2020Q10006UDetc ia meds 120+ analytesFalseNational246.92
2020Q10007MOnc gastro 51 gene nomogramFalseNational375.0