OIG review of Medicare payments for clinical laboratory tests: 64% of 2017 payments were for 25 tests

Upon reviewing 2017 claims data for laboratory tests paid for under Medicare’s Clinical Laboratory Fee Schedule (CLFS), the Office of Inspector General (OIG) found that most payments were for 25 tests. Payment totals for lab tests have remained consistent over the past four years but may be subject to change under a new payment system.

Effective in 2018, CMS changed the way it sets payment rates for clinical diagnostic laboratory tests covered under Medicare Part B. The new payment rates are based on rates paid by private payers and have replaced the previous system, which based payment rates on charges from 1984 and 1985.

To gather baseline data, the OIG analyzed Part B payments made in 2017—the final year for which CMS paid for lab tests under the pre-2018 system. The analysis was based on services paid for under Medicare’s CLFS and did not include tests paid for under other payment systems such as the OPPS.

According to the OIG’s findings, Medicare Part B paid $7.1 billion for laboratory tests in 2017, a total that has changed little over the past four years. The report indicates that 64% of this total can be attributed to payments for 25 laboratory tests.

Notably, five laboratory tests have maintained their respective position among the top 25 tests for the last four years and accounted for 30% ($2.2 billion) of all payments for laboratory tests in 2017.

The laboratory tests that have consistently resulted in the most payments for Medicare Part B services include four common blood tests and a test for Vitamin D3 levels. These tests, listed by total payment amount for 2017 and identified by CPT code descriptor, are:

• 84443, thyroid stimulating hormone; $484 million
• 80053, comprehensive metabolic panel including albumin (82040), total bilirubin (82247), total calcium (82310), carbon dioxide (82374), chloride (82435), creatinine (82565), glucose (82947), alkaline phosphatase (84075), potassium (84132), total protein (84155), sodium (84295), alanine amino transferase (84460), aspartate amino transferase (84450), and urea nitrogen (84520); $473 million
• 85025, automated complete blood count performed with or without automated differential white blood cell count; $432 million
• 80061, lipid panel including total cholesterol serum (82465), total lipoprotein (direct measurement, high density cholesterol) [83718], triglycerides (84478); $415 million
• 82306, 25-hydroxyvitamin D levels including fraction(s), if performed; $348 million

A list of the top 25 tests by Medicare payment amount is included in the brief.

The OIG plans to use these statistics to measure the impact of the new payment system in next year’s analysis of 2018 Medicare Part B payments.