Did You Catch It? New Year, New Look for CLFS

Medicare CLFS 2018

Your 2018 preparations for lab coding aren’t complete if you haven’t looked into the changes to the Clinical Laboratory Fee Schedule (CLFS). Here are some hints from Pathology/Lab Coder to point you in the right direction.

Get an Overview of the CLFS Makeover

The 2018 CLFS brought a major overhaul to payment for lab testing. This year’s CLFS provides one national payment rate for each lab code (with some exceptions being marked as locally priced).

As an example of the new national approach, if you look up comprehensive metabolic panel code 80053, you’ll see a national rate of $13.04 listed. In the 2017 fee schedule, you would have seen additional columns. Some example of old columns include national limit ($14.49 for 80053 in 2017 Q4), midpoint ($19.59 for 80053 in 2017 Q4), and locality-based pricing.

The Protecting Access to Medicare Act (PAMA) had a stated goal of using the weighted median of private payer rates for lab tests, and the CLFS changes are based on that. One point critics of the new system make is that CMS got the vast majority of data used for pricing decisions from independent labs. A disproportionately small amount of information came from hospitals and physician services, they say.

Under the new system, many labs will see reduced rates for common lab tests. CMS is phasing in payment reductions over several years by capping how much a fee can be reduced each year. In 2018, the reduction is capped at 10 percent. There are also a few tests, notably molecular analyses, that will see increases.

Round Out Your Knowledge With These Exceptions

There are some small subsets of lab codes not subject to the new approach to pricing in 2018.

  1. New codes for the year: The process for pricing new codes will continue to be the one you’re familiar with. CMS holds a public meeting to gather comments that the agency considers when determining pricing. Pricing methods include a crosswalk to an existing code and gapfill pricing to gather payment data before setting a rate.
  2. Codes with no data available for 2018 CLFS: The data CMS used to set the 2018 pricing was gathered over six months in 2016. That means that, for the 2018 price-setting, CMS didn’t have information on all codes now available, especially those new in 2017. CMS used crosswalk pricing to determine 2018 payment for these.
  3. Advanced Diagnostic Laboratory Tests (ADLTs): Specific criteria define an ADLT, such as being furnished by a single lab. CMS pays the actual list charge (based on the first day the ADLT is available) for three quarters and then uses the private payer weighted median to set the price for an ADLT.

What About You?

What’s your view of the overhauled CLFS? Have you checked how reimbursement will change for your top tests?


Deborah works on a wide range of TCI SuperCoder projects, researching and writing about coding, as well as assisting with data updates and tool development for our online coding solutions. Since joining TCI in 2004, she’s covered the ins and outs of coding for radiology, cardiology, oncology and hematology, orthopedics, audiology, and more.

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