Section 216 of the PAMA law of 2014 requires labs to report private payor pricing every 3 years to CMS, which CMS then uses to set a triennial Medicare lab fee schedule.
The first cycle involved a claims period in 1H2016, reporting in 1Q2017, CMS publications in September 2017, and a 3-year fee schedule for 2018, 2019, 2020. Due to some quirks and updates to PAMA law, the next three year cycle is atypical. The claims period is still 1H2019, but data will be reported in 1Q2022 (not 1Q2020), for price publication in September 2022 and a fee schedule for 2023, 2024, 2025.
On April 20, 2021, CMS updated some documents on its website for PAMA lab pricing policy.
- The main webpage is here.
- At least two documents have been updated:
- Summary of Private-Payor Rate-Based CLFS, 10 page PDF, here.
- FAQ, 14 page PDF, here.
The regulations upon which the guidelines and FAQs are based are found at 42 CFR 414.500ff, here.
What Will Happen to Codes Newer than the 2019 Claims Period?
Nerd note. A person can redline two PDFs in a business version of Adobe Acrobat, but it's kind of expensive software. If you google "redline 2 PDFs" you'll get some cloud websites that allow the redline action between two PDFs. E.g. https://tools.pdfforge.org/compare-pdf