Last month, the Centers for Medicare & Medicaid Services (CMS) announced quarterly changes affecting lab test reporting and billing under the Medicare Part B Clinical Laboratory Fee Schedule (CLFS). The changes take effect on July 1, 2022. Here are the two key CLFS changes your billing staff needs to know about.

1. Delay in PAMA Reporting

After two years of delay, the 2022 CLFS was supposed to include a Protecting Access to Medicare Act of 2014 (PAMA)-required 15 percent phase-in reduction in Part B reimbursements for Clinical Diagnostic Laboratory Tests (CDLTs). But on December 10, 2021, Congress passed legislation (the Protecting Medicare and American Farmers from Sequester Cuts Act) delaying application of the 15 percent cut for at least another year.

Under the CLFS final rule, labs and other reporting entities must give CMS certain private payor rate information for their component applicable laboratories. The data collection period was for claims for which final payment was received from January 1, 2019, to June 30, 2019. But CMS has reshuffled the reporting timetables in accordance with the delays in phasing in the 15 percent cuts. Specifically, it has based the next data reporting period of January 1, 2023, to March 31, 2023, on the original data collection period of January 1, 2019, to June 30, 2019. After the next data reporting period, there will be a three-year data reporting cycle for CDLTs that aren’t Advanced Diagnostic Laboratory Tests (ADLTs) (2026, 2029, etc.).

CMS has also extended the statutory phase-in of payment reductions resulting from private payor rate implementation through calendar year (CY) 2025. There’s a 0.0 percent reduction for CY 2021 and CY 2022, and the agency won’t reduce payment by more than 15 percent for CYs 2023-2025.

2. The New PLA Codes

In addition to the PAMA changes, CMS added nine new Proprietary Laboratory Analysis (PLA) CPT codes to the national Healthcare Common Procedure Coding System (HCPCS) file that will be recognized starting July 1, 2022. Medicare administrative contractors will decide how much labs in their jurisdiction will be reimbursed for the new PLA codes until a national price is set via the CLFS annual payment determination process.

Newly Listed PLA Codes, Effective July 1, 2022

Source: CMS Manual System, Pub 100-04 Medicare Claims Processing, Transmittal 11398

Note: All codes are listed as TOS 5