2018 Medicare Laboratory Fee Schedule (MLFS)

Which Medicare MAC has the best laboratory reimbursement?

Apache Health often gets questions about which locality or which Medicare region (MAC) has the best reimbursement rates.  Even a number of years ago some labs sought to locate in favorable reimbursement locations in order to maximize their reimbursement.  None of that matters any longer. 

Under changes required by the law Protecting Access to Medicare Act of 2014, also known as PAMA, the separate fee schedules or modifications by location have been eliminated.  The 57 localities eliminated and there is now one national price for all CPTs for laboratory billing.  PAMA was originally signed into law in 2014, delayed to 2015, and major provisions that have wide-reaching implications for laboratory billing went into effect Jan 1, 2018.

Here is what the 2017 Medicare clinical diagnostic laboratory fee schedule looked like:

Screenshot of 2018 Medicare Laboratory Fee Schedule (MLFS)-1

*(with columns going far off to the right for every locality in the country)

 

vs the 2018 Medicare clinical diagnostic laboratory fee schedule where you will see there are no longer any variances by locality:

 

2018 Clinical Diagnostic Laboratory Fee Schedule  
CPT codes, descriptions and other data only are copyright 2018 American Medical Association. All rights reserved. CPT is a registered trademark of the American Medical Association (AMA).
             
HCPCS MOD EFF_DATE INDICATOR RATE2018 SHORTDESC  
0001M   20180101 N 00072.19 Infectious dis hcv 6 assays
0001U   20180101 L 00000.00 Rbc dna hea 35 ag 11 bld grp
0002M   20180101 N 00503.40 Liver dis 10 assays w/ash
0002U   20180101 L 00000.00 Onc clrct 3 ur metab alg plp
0003M   20180101 N 00503.40 Liver dis 10 assays w/nash
0003U   20180101 N 00950.00 Onc ovar 5 prtn ser alg scor
0004M   20180101 L 00000.00 Scoliosis dna alys
0005U   20180101 N 00760.00 Onco prst8 3 gene ur alg
0006M   20180101 L 00000.00 Onc hep gene risk classifier
0006U   20180101 N 00246.92 Rx mntr 120+ drugs & sbsts
0007M   20180101 L 00000.00 Onc gastro 51 gene nomogram
0007U   20180101 N 00114.43 Rx test prsmv ur w/def conf
0008U   20180101 N 00597.91 Hpylori detcj abx rstnc dna
0009M   20180101 L 00000.00 Fetal aneuploidy trisom risk
0009U   20180101 L 00000.00 Onc brst ca erbb2 amp/nonamp
0010U   20180101 L 00000.00 Nfct ds strn typ whl gen seq
0011U   20180101 N 00114.43 Rx mntr lc-ms/ms oral fluid
0012U   20180101 L 00000.00 Germln do gene reargmt detcj
0013U   20180101 L 00000.00 Onc sld org neo gene reargmt
0014U   20180101 L 00000.00 Hem hmtlmf neo gene reargmt
0016U   20180101 N 00202.42 Onc hmtlmf neo rna bcr/abl1
0017U   20180101 N 00113.17 Onc hmtlmf neo jak2 mut dna
36415   20180101 N 00003.00 Routine venipuncture
78267   20180101 N 00011.06 Breath tst attain/anal c-14
78268   20180101 N 00094.41 Breath test analysis c-14
80047   20180101 N 00013.73 Metabolic panel ionized ca
80047 QW 20180101 N 00013.73 Metabolic panel ionized ca
80048   20180101 N 00010.44 Metabolic panel total ca
80048 QW 20180101 N 00010.44 Metabolic panel total ca
80051   20180101 N 00008.66 Electrolyte panel
80051 QW 20180101 N 00008.66 Electrolyte panel
80053   20180101 N 00013.04 Comprehen metabolic panel
80053 QW 20180101 N 00013.04 Comprehen metabolic panel
80055   20180101 N 00059.02 Obstetric panel
80061   20180101 N 00016.53 Lipid panel  
80061 QW 20180101 N 00016.53 Lipid panel  

*(only showing first few lines)

The full Medicare Laboratory Fee Schedule for 2018 can be found here:

https://www.cms.gov/apps/ama/license.asp?file=/Medicare/Medicare-Fee-for-Service-Payment/ClinicalLabFeeSched/Downloads/18CLAB.zip

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Legal disclaimer: Apache Health is engaged in the business of healthcare revenue cycle management analytics.  We offer information about regulations, rules, and industry practices relating to compliance.  Apache has researched that subject and has set forth the results of that research herein.  Apache Health is not a law firm and we do not offer legal advice.  Apache does not guarantee the completeness nor the accuracy of its research.  You should consult with your qualified healthcare attorney.

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