Clinical Lab Reporting Requirements Updated for 2019

Posted on January 10, 2019

In the 2019 Medicare physician fee schedule (PFS) final rule, the Centers for Medicare & Medicaid Services (CMS) modified the definition of “applicable laboratories” to include hospital laboratories that bill Medicare for nonpatient laboratory services on the CMS 1450 14X type of bill (TOB). This change requires all hospital outreach laboratories that use the CMS 1450 14X TOB to report their private payer rate and volume data during the 2020 data reporting period (Jan. 1 through March 31, 2020) unless they receive less than $12,500 in Medicare payments during the period of Jan. 1 through June 30, 2019. 

Effective Jan.1, 2018, the Medicare clinical laboratory fee schedule (CLFS) payment rates are based on the national weighted median of private payer rates reported by certain “applicable laboratories.” Previously, the CMS defined “applicable laboratories” as laboratories that billed Medicare Part B under their own National Provider Identifier and received more than 50 percent of their Medicare revenues during the period of Jan. 1 through June 30 from PFS and CLFS services. Laboratories that received less than $12,500 in Medicare payments for CLFS services during the six-month data collection period were exempt from the reporting requirements.

In the 2019 rule, the CMS also finalized its proposal to remove payments from Medicare Advantage (MA) plans from the calculation used to determine whether a lab received more than 50 percent of its revenues from PFS and CLFS services. The CMS believes that excluding MA plan revenues from total Medicare revenues will increase the number of labs subject to the reporting requirements.  

On Jan. 22, the CMS will host a call explaining the data collection and reporting requirements. Hospitals with outreach labs that bill on the CMS 1450 14X TOB are encouraged to register for the call, which will include a question-and-answer session. Members with questions should contact Vickie Kunz at the MHA.

Tags: Medicare, CLFS, hospital outreach laboratories, laboratory services

Posted in: Member News

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