Is Your Lab Aware of CMS Claim Requirements for “Unlisted” Test Codes?

October 17, 2017 By: Quadax

Is your laboratory’s claims and reimbursement processing ready to handle CMS changes?

Centers for Medicare & Medicaid Services (CMS) released Transmittal 3881 on Friday, Oct. 13, 2017 requiring the submission of data for lab tests processed with “unlisted” codes effective beginning January 16, 2018. Medicare Contractors (MACs) will report to CMS specific laboratory tests and associated claims data for any test paid under the Clinical Laboratory Fee Schedule (CLFS) as a Not Otherwise Classified (NOC), Not Otherwise Specified (NOS), or an Unlisted Service or Procedure code, including but not limited to the following: 81099, 81479, 81599, 84999, 85999, 86849, 86999, 87999, 88749 and 89398. Claims that fail to follow the new procedures will be returned as unprocessable.

The PAMA Impact

Section 216(a) of the Protecting Access to Medicare Act of 2014 (PAMA) added Section 1834A to the Social Security Act (the Act), which requires revisions to the payment methodology for clinical diagnostic laboratory tests paid under the CLFS. PAMA requires reporting entities to report private payer payment rates for laboratory tests and the corresponding volumes of tests. To be in compliance with PAMA, CMS is instructing MACs to assure that providers submit private payer data on unique tests currently being paid as a NOC code, NOS code, or Unlisted Service or Procedure code effective beginning January 16, 2018.

CMS Claim Requirements – What Your Lab Needs to Know

CMS updates to the “Medicare Claims Processing Manual,” Chapter 26, “Completing and Processing Form CMS-1500 Data Set,” clarify how providers of service or suppliers should populate field 19 of the form when billing NOC codes. Specifically, when billing for unlisted laboratory tests using a NOC code, field 19 must be populated with the specific name of the laboratory test(s) and/or a short descriptor of the test(s). MACs will gather the claims data on specific laboratory tests being paid under the CLFS as a NOC, a NOS, or an unlisted service or procedure code and report it to CMS on a quarterly basis.

Issues for Labs

How will CMS define a “unique” test? Laboratories may need to create a “specific name of the laboratory test(s) and/or short descriptor of the test(s)” to correspond with that definition. This may present challenges as most CMS “unlisted” codes fall within the MolDX program and may require running multiple gene panel tests.


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