CY 2018 CLFS – Final Payment Rates and Crosswalking/Gapfilling Determinations

December 2017 ~

CMS has published final payment rates and supporting documentation for the new private payor rate-based Clinical Lab Fee Schedule (CLFS) payment system, to be implemented on January 1st, 2018. As well, the agency has also released final CY 2018 CLFS determinations on gapfilling and/or crosswalking methodologies for new laboratory tests and laboratory tests with no reported private payor rate information.

The final rule, titled Medicare Program: Medicare Clinical Diagnostic Laboratory Tests Payment System (CMS-1621-F) and published in the Federal Register on June 23, 2016, implements section 216 of the Protecting Access to Medicare Act (PAMA) of 2014. Under the rule, laboratories, including physician office laboratories, are required to report private payor rate and volume data if they:

  • Have more than $12,500 in Medicare revenues from laboratory services on the CLFS and
  • Receive more than 50 percent of their Medicare revenues from laboratory and physician services during a data collection period.

Tests that meet the criteria for being considered new advanced tests will be paid at actual list charge during an initial period of three calendar quarters. Once the initial period is over, payment for new, advanced tests would be based on the weighted median private payor rate reported by the single laboratory that performs the new ADLT. Advanced tests are tests furnished by only one laboratory that include a unique algorithm and, at a minimum, are an analysis of RNA, DNA or proteins or are cleared or approved by the U.S. Food and Drug Administration (FDA).

For more information and complete details on the final rule, see the CY 2018 Final Crosswalking/Gapfilling Determinations, CY 2018 Final Private Payor Rate-Based CLFS Payment Rates [ZIP, 413KB] , and the HCPCS Codes with Revised Final CY 2018 Private Payor Rate-Based CLFS Payment Rates and Clarifications Regarding the Weighted Median Calculations [PDF, 614KB].



Source(s): CMS;