News & Analysis

January 23, 2017
Medicare Insider

This week’s Medicare updates include additional guidance on the MOON form, an NCA for leadless pacemakers, delayed implementation of the (ESRD) Interim Final Rule – Third Party Payment, and more!

January 1, 2017
Briefings on APCs

Managers should not assume that they can review every guideline, every item in Coding Clinic, or every coding-related issue targeted by the Office of Inspector General or Recovery Auditor. 

December 1, 2016
Briefings on APCs

As it does each year, CMS reviewed its packaging policies and proposed numerous modifications for 2017, finalizing a move to conditionally package at the claim level and deleting the controversial modifier used to identify separately reportable laboratory tests. 

October 5, 2016
Medicare Insider

This week’s Medicare updates include a transmittal recurring update notification describing changes to and billing instructions for various payment policies implemented in the October 2016 OPPS update; news about CMS once again allowing some providers to settle inpatient status claims in appeals; an OIG report regarding the improper payment of millions of dollars for unlawfully present beneficiaries; and more!

August 1, 2016
Briefings on APCs

CMS issued a final rule in June to revamp the way it pays for tests under the Clinical Laboratory Fee Schedule (CLFS), though the agency has pushed the start date back a year and worked to ease administrative burden based on public comments.

"This, along with some other changes CMS finalized based on commenter concerns and additional analyses, is really good news for providers," says Jugna Shah, MPH, president and founder of Nimitt Consulting, Inc. "It's all in the spirit of reducing provider burden."

Now starting January 1, 2018, CMS will base CLFS payments on the weighted median amount paid by private payers for the same services. Providers are hopeful that these new weighted median rates based on a different process from the existing CLFS updating process, which has remained relatively unchanged since its establishment in 1984, will result in more accurate rates, says Shah.


In order to develop the new rates, CMS will require "applicable laboratories to report applicable information" to the agency.

An applicable lab is defined as one that receives at least $12,500 in payments under the CLFS, and more than 50% of Medicare revenue from laboratory and/or physician services over the data reporting period to report private payer rates and test volumes for laboratory tests.

These thresholds will exclude approximately 95% of physician office laboratories and 55% of independent laboratories from having to report information, along with just about all hospital labs, according to CMS.

The applicable information required to be reported is:

  • The payment rate that was paid by each private payer for each test during the data collection period
  • The volume of such tests for each such payer

CMS originally proposed to use Taxpayer Identification Numbers (TIN) to identify applicable laboratories, but in the final rule made a change to use National Provider Identifiers (NPI). In order to keep administrative burden at a minimum, CMS will continue to apply the reporting requirements at the TIN level, making those entities responsible for reporting all NPI-level information for its applicable laboratories.

CMS also clarified that the information that must be reported is tied to payments received, which means that if a claim was submitted but payment was not yet received or was denied, that data would not be reported to CMS.

The data reporting period has been shortened from one year in the proposed rule to six months in the final rule. The first data collection period is from January 1‑June 30, 2016. That collected data will have to be reported to CMS from January 1‑March 31, 2017.

CMS plans to follow this schedule for subsequent collecting and reporting periods, which will occur every three years for all CLFS tests except Advanced Diagnostic Laboratory Tests (ADLT), which will have more frequent data collection and updating.

CMS has defined an ADLT as a clinical diagnostic laboratory test that is covered under Medicare Part B and offered and furnished by only a single laboratory, and only sold for use by the original developing laboratory, or a successor owner.

The test must also meet the following criteria:

  • The test is an analysis of multiple biomarkers of DNA, RNA, or proteins combined with a unique algorithm to yield a single patient-specific result
  • the test is cleared or approved by the Food and Drug Administration (FDA)
  • the test meets other similar criteria established by the secretary of HHS

In response to public comments to the proposed rule, CMS changed the definition of ADLTs, which originally only included molecular pathology analysis and did not include protein-only based tests.

ADLTs have been established by the agency in order to recognize when a laboratory has expended all of the resources associated with a test, including development, marketing, and selling.

The $12,500 threshold for CLFS payments will not apply with respect to ADLTs. If a laboratory would otherwise meet the definition of applicable, excepting the $12,500 threshold, CMS will consider it applicable with respect to the ADLT and it must report the applicable information pertaining to the ADLT.

July 8, 2016
Medicare Web

CMS proposes aligning its conditional packaging modifiers and deleting a much-maligned modifier for separately payable laboratory tests in the 2017 OPPS proposed rule, released July 6.