Medical practices that run labs are in for fluctuating reimbursement come Jan. 1, with 897 lab codes in line for a 10% dip in payment and another 109 codes seeing a pay boost of 10% or more.
The volatile pay shift comes as CMS implements part of the Protecting Access to Medicare Act (PAMA) of 2014, which stipulates that Medicare payment rates for lab tests must match the average price point of private insurers. The rates, which CMS
recently finalized, will impact lab-test payments for at least the next three years.
That means clinical labs, including those within physician offices, will face a startling new payment structure in 2018 when it comes to some of their most frequently performed tests, which
are reported millions of times per year. For instance, providers reported two of the tests facing a pay cut -- complete CBC (
85025) and comprehensive metabolic panel (
80053) -- more than 30 million times each, according to the latest available Medicare claims data from 2016.
Don't get too comfortable with the rates you see on Jan. 1. Because CMS is limited to a maximum yearly rate reduction of 10%, more cuts are coming for many of the codes in 2019 and 2020, according to CMS documents.
But it's not all red ink next year. In fact, 145 tests will see a pay boost, with 109 of them garnering at least a 10% jump and 33 tests increasing by 100% or more. Take hepatitis C screening code G0472, for example. It's on track for a rate increase of 137%, moving the needle to $26.78 in 2018 from its previous pay rate of $19.57. The biggest winner next year? That would be urine-screening code 81007, treated to a whopping 752% pay jump, which turns a measly $3.52 into more than $26.