2012 CLFS Update Addresses New Molecular Pathology Codes

The 2012 annual update to the Clinical Laboratory Fee Schedule (CLFS) is anything but a quick read. In addition to the 2012 CLFS update, a Recurring Update Notification (RUN) provides instructions for mapping new codes for clinical laboratory tests and coding new molecular pathology procedure test codes, and updates for laboratory costs subject to the reasonable charge payment.

2012 Fee Update

Effective Jan. 1, 2012, the annual update to the local CLFS is 0.65 percent. This update reflects an additional multi-factor productivity adjustment and a -1.75 percentage point reduction. The annual 2012 update to payments made on a reasonable charge basis for all other lab services is 3.6 percent.

The national minimum payment amount is $14.97. The affected codes are: 88142, 88143, 88147, 88148, 88150, 88152, 88153, 88154, 88164, 88165, 88166, 88167, 88174, 88175, G0123, G0143, G0144, G0145, G0147, G0148, and P3000.

For lab costs subject to reasonable charge payment, the inflation-indexed update for 2012 is 3.6 percent. See Transmittal 2365, released Dec. 9, for a list of HCPCS Level II codes to which the reasonable charge basis applies when performed in an independent dialysis facility.

Molecular Pathology Procedure Test Codes

Beginning Jan. 1, 2012, there will be 101 additional molecular pathology procedure test codes (listed in Transmittal 2365) established by the American Medical Association (AMA). For payment purposes, under CLFS these test codes will be assigned a “B” indicator. This means, “Payment for covered services is always bundled into payment for other services not specified. There will be no RVUs or payment amounts for these codes and no separate payment is ever made. When these services are covered, payment for them is subsumed by the payment for the services to which they are incident (an example is a telephone call from a hospital nurse regarding care of a patient),” the Centers for Medicare & Medicaid Services (CMS) cites in transmittal 2365.

While the allowed charge amount will be $0.00 for these codes, Medicare claims should reflect a charge for non-payable services.

Also beginning Jan. 1, 2012, Medicare claims for these services should reflect both the existing CPT® “stacked” test codes and the new single CPT® test code. CMS provides this example:


Laboratory A would report the existing stacked set of codes that are required to receive payment [i.e., 83891 (one time) + 83898 (multiple times) + 83904 (multiple times) + 83909 (multiple times) + 83912 (one time)] along with the new, single CPT test code that corresponds to the test represented by the “stacked” test codes.

For 2012, there are no new test codes that need to be gap-filled, but you will find mapping information for several codes in the CMS transmittal.

2 Responses to “2012 CLFS Update Addresses New Molecular Pathology Codes”

  1. Jennifer Rustan says:

    Is anyone concerned that by including these new code names we may see denials for medical necessity? Is this strictly a ‘data collection and research’ request, do we think? Is anyone choosing NOT to include the new codes as ‘requested’ on their 2012 claims? If so, do you expect to see denial because they are missing?

  2. Henry Allen says:

    Qualchoice has denied my claim for cpt code 88120 (Cytopathology,in Situ Hybridrization: Manual), say that it is an experimental procedure. Medicare is primary and paid their part, approving it medical necessity. Any suggestions on what to do would be appreciated. Henry Allen

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