CMS Pub. 100-04, ch. 16, § 20.1

Initially, each A/B MAC (B) established the fee schedules on an A/B MAC (B)-wide basis (not to exceed a

statewide basis). If an A/B MAC (B)’s area includes more than one State, the A/B MAC (B) established a

separate fee schedule for each State. The A/B MAC (B) determined the fee schedule amount based on

prevailing charges for laboratory billings by physicians and independent laboratories billing the A/B MAC

(B). A/B MACs (B) set the fees at 60 percent of prevailing charges. A/B MACs (A) used the same fee

schedules to pay outpatient hospital laboratory services. They set the fee at 62 percent of A/B MAC (B)

prevailing charges. Subsequently, except for sole community hospitals, which continue to be paid at the 62

percent rate, A/B MACs (A) changed payments to hospital laboratories to the “60 percent fee schedule.”

In 1994, CMS took over the annual update and distribution of clinical laboratory fee schedules. The CMS

updates the fee schedule amounts annually to reflect changes in the Consumer Price Index (CPI) for all Urban

Consumers (U.S. city average), or as otherwise specified by legislation.

Effective for hospital outpatient tests furnished by a hospital on or after April 1, 1988, to receive the 62

percent fee the hospital must be a sole community hospital. Otherwise, the fee is the “60 percent fee schedule.”

If a hospital is uncertain whether it meets the qualifications of a sole community hospital it can seek assistance

from the A/B MAC (A) or the RO.

For tests to hospital non-patients, the fee is 60 percent of the A/B MAC (B) prevailing charge. If a hospital

laboratory acts as an independent laboratory, i.e., performs tests for persons who are nonhospital patients; or if

the hospital laboratory is not a qualified hospital laboratory, the services are reimbursed using the 60 percent

fee schedule or the adjusted fee schedule, as appropriate.

See §10.1 for the definition of a hospital outpatient.

See §20.3 for CLFS effective January 1, 2018.