CMS Pub. 100-04, ch. 16, § 90.1.1

B3-5114, HO-437, A3-3628, PMs AB-97-5, AB-97-7, AB-97-17

Profiles are specific groupings of blood chemistries that enable physicians to more

accurately diagnose their patients’ medical problems. While the component tests in

automated profiles may vary somewhat from one laboratory to another, or from one

physician’s office or clinic to another, in order to develop appropriate payment amounts,

A/B MACs (A) and (B) group together those profile tests that can be performed at the

same time on the same equipment. The A/B MAC (A) or (B) must group together the

individual tests in the profile when billed separately and consider the price of the related

automated profile test. Payment cannot exceed the lower of the profile price or the totals

of the prices of all the individual tests. (This rule is applicable also if the tests are done

manually.) The profile HCPCS code and each individual test is priced at the lower of the

billed charge or the fee amount; and payment is made at the lower of the profile/panel

price or the total of the prices for all covered components.

Payment is made only for those tests in an automated profile that meet Medicare

coverage rules. Where only some of the tests in a profile of tests are covered, payment

cannot exceed the amount that would have been paid if only the covered tests had been

ordered. For example, the use of the 12-channel serum chemistry test to determine the

blood sugar level in a proven case of diabetes is unreasonable because the results of a

blood sugar test performed separately provide the essential information. Normally, the

payment allowance for a blood sugar test is lower than the payment allowance for the

automated profile of tests. In no event, however, may payment for the covered tests

exceed the payment allowance for the profile.

However, the A/B MAC (B) prices and pays the 1-22 automated multi-channel chemistry

tests tested in §90.2 at the lowest possible amount in accordance with §90.3.

As of January 1, 2018, the profiles referenced in the above section are no longer

recognized by Medicare. The Protecting Access to Medicare Act of 2014 requires

Medicare to pay a weighted median collected from private payor rates for each

HCPCS code on the CLFS. Therefore the automated profiles described above are

no longer used to pay for the automated profiles of tests.