Tuesday, January 3, 2023

Brief Blog: CMS Publishes 2023 Lab Fee Schedule

I noted in a prior blog that CMS had updated its webpage of PAMA rules, indicating 0% PAMA-based lab fee cuts in CY2023.  This is based on the December 2022 federal budget bill.

On January 3, 2023, CMS published the full A to Z lab fee schedule for CY2023.  I believe the publication was delayed due to pending legislation and uncertainty.

Find the 2023 fee schedule here:


See related PDF file, "CR 13023," here.  This file is 21 pages long and includes crosswalk/gapfill instructions and new code information (e.g. PLA codes from 0355U up).


Total Codes; PLA Codes

The lab fee schedule is 1922 codes long this quarter.  Almost 400 of those are PLA codes.

Gapfill Codes

It looks like about 45 codes are in the "gapfill" process because they have indicator "L" locally priced and fee schedule price "0".  A G-code created in 2021, G0327, remains priced at "0" or unpriced; this is not in gapfill but is a placeholder code for liquid biopsy colon cancer screening test (no such test is yet approved by FDA).

Price Ranges

Prices run from $2.17 urinalysis to 0211U, tumor exome and other sequencing, $8455.   (I'm leaving out code 81416 which is "exome sequence analysis, comparator exome" and is an anomalous price at $12,000 (!!)  resulting from the PAMA 2018 process.)  

A dozen codes are $5000 and up. 


Fee schedule prices generally remain exactly the same as last year (e.g. tumor panel 81455 is $2919.60 again).  Sequestration federal budget cuts (e.g. -2%) apply after the fee schedule process (read here, question 4) and during actual payment, "claim adjustment reason #253 sequestration" is applied.

Long Descriptors in 2023 Column "I"

In some past quarters - I had Q12022 handy - CMS lists code, price, short descriptor (provided by AMA, limited to around 25 characters) and a "long descriptor" which to my knowledge isn't generated by AMA and is often 5-8 words long (for PLA codes).

Last quarter and this quarter, Q12023, CMS lists short descriptor (provided by AMA), that "long descriptor" (often 5-8 words) and then, the entire long descriptor (the full code text) published by AMA.

Like this, 2022:

And with AMA full text long descriptor now in Q1 2023: