Clinical Laboratory Services Rate Methodology
July 2020 Update:
The Department of Health Care Services (DHCS) has calculated the proposed Clinical Laboratory rates, effective July 1, 2020 in compliance with California Welfare and Institutions Code section 14105.22.
The following proposed Medi-Cal fee-for-service rates are contingent on federal approval of State Plan Amendment (SPA) 20-0010.
|CPT Codes||CPT Code Description|
July 1, 2020 Rate
|80305||DRUG TEST PRSMV DIR OPT OBS || $9.98 |
|82120||AMINES VAGINAL FLUID QUAL|| $3.22 |
|82172||ASSAY OF APOLIPOPROTEIN|| $12.96 |
|82270||OCCULT BLOOD FECES|| $2.48 |
|82962||GLUCOSE BLOOD TEST|| $1.57 |
|83020||HEMOGLOBIN ELECTROPHORESIS|| $9.57 |
|83050||BLOOD METHEMOGLOBIN ASSAY|| $6.17 |
|83789||MASS SPECTROMETRY QUANT|| $16.28 |
|84402||ASSAY OF FREE TESTOSTERONE|| $4.45 |
|84443||ASSAY THYROID STIM HORMONE|| $11.20 |
|84466||ASSAY OF TRANSFERRIN|| $6.92 |
|84480||ASSAY TRIIODOTHYRONINE (T3)|| $8.82 |
|84681||ASSAY OF C-PEPTIDE|| $4.53 |
|85025||AUTOMATED HEMOGRAM|| $3.33 |
|85046||RETICYTE/HGB CONCENTRATE|| $3.56 |
|85049||AUTOMATED PLATELET COUNT|| $3.39 |
|85060||BLOOD SMEAR INTERPRETATION|| $5.25 |
|85097||BONE MARROW INTERPRETATION|| $34.85 |
|85613||RUSSELL VIPER VENOM DILUTED|| $5.80 |
|85660||RBC SICKLE CELL TEST|| $3.77 |
|86038||ANTINUCLEAR ANTIBODIES, RIA|| $6.47 |
|86141||C-REACTIVE PROTEIN HS|| $7.16 |
|86147||CARDIOLIPIN ANTIBODY EA IG|| $16.60 |
|86300||IMMUNOASSAY TUMOR CA 15-3|| $16.14 |
|86317||IMMUNOASSAY INFECTIOUS AGENT|| $5.90 |
|86334||IMMUNOFIX E-PHORESIS SERUM|| $14.89 |
|86359||T CELLS TOTAL COUNT|| $29.54 |
|86480||TB TEST CELL IMMUN MEASURE|| $5.46 |
|86635||COCCIDIOIDES ANTIBODY|| $6.39 |
|86677||HELICOBACTER PYLORI ANTIBODY|| $12.45 |
|86702||HIV-2 ANTIBODY|| $10.77 |
|86870||RBC ANTIBODY IDENTIFICATION|| $11.32 |
|86906||BLOOD TYPING RH PHENOTYPE|| $4.76 |
|87040||BLOOD CULTURE FOR BACTERIA|| $8.25 |
|87186||MICROBE SUSCEPTIBLE MIC|| $5.77 |
|87209||SMEAR COMPLEX STAIN|| $3.10 |
|87255||GENET VIRUS ISOLATE HSV|| $8.00 |
|87389||HIV-1 AG W/HIV-1 & HIV-2 AB|| $14.04 |
|87480||CANDIDA DNA DIR PROBE|| $15.35 |
|87486||CHYLMD PNEUM DNA AMP PROBE || $23.14 |
|87491||CHYLMD TRACH DNA AMP PROBE|| $27.90 |
|87502||INFLUENZA DNA AMP PROBE|| $52.98 |
|87512||GARDNER VAG DNA QUANT|| $26.87 |
|87536||HIV-1 QUANT&REVRSE TRNSCRPJ|| $45.10 |
|87631||RESP VIRUS 3-5 TARGETS || $45.00 |
|87633||RESP VIRUS 12-25 TARGETS|| $139.79 |
|87653||STREP B DNA AMP PROBE|| $24.68 |
|87661||TRICHOMONAS VAGINALIS AMPLIF|| $26.27 |
|87806||HIV ANTIGEN W/HIV ANTIBODIES || $17.12 |
|88104||CYTOPATH FL NONGYN SMEARS|| $10.39 |
|88108||CYTOPATH CONCENTRATE TECH|| $22.67 |
|88112||CYTOPATH CELL ENHANCE TECH|| $59.93 |
|88172||CYTP DX EVAL FNA 1ST EA SITE || $25.58 |
|88184||FLOWCYTOMETRY/ TC 1 MARKER|| $32.67 |
|88189||FLOWCYTOMETRY/READ 16 & >|| $30.58 |
|88302||TISSUE EXAM BY PATHOLOGIST|| $18.02 |
|88307||TISSUE EXAM BY PATHOLOGIST|| $76.30 |
|88312||SPECIAL STAINS GROUP 1|| $26.78 |
|88350||IMMUNOFLUOR ANTB ADDL STAIN || $63.83 |
|84311||SPECTROPHOTOMETRY || $6.12 |
|G0482||DRUG TEST DEF 15-21 CLASSES || $126.22 |
|G0483||DRUG TEST DEF 22+ CLASSES || $160.47 |
In accordance with Assembly Bill (AB) 1494 (Committee on Budget), the DHCS is required to:
Implement a ten percent payment reduction, excluding services under the Family Planning, Access, Care and Treatment (FPACT) program and outpatient hospital services, effective July 1, 2012 through June 30, 2015, for clinical laboratory and laboratory services until a new rate setting methodology is approved by the Centers for Medicaid & Medicare Services (CMS).
As required by statute, the AB 97 payment reduction is also applied to the new payment methodology.
Data Collection Process
DHCS underwent a significant stakeholder process to develop the data collection tool to be used for the development of the new methodology and to determine the new rates under that methodology.
Beginning in 2012, DHCS conducted meetings with clinical laboratory stakeholders to develop a data collection methodology that was operationally feasible and consistent with the intent of the legislation.
DHCS requested third-party payer rate and utilization data from providers and limited the use of data to codes that met either of the following two thresholds based on the prior year's Medi-Cal paid claims data:
Medi-Cal paid claims volume equal to or greater than 1,000
Total Medi-Cal paid amount equal to or greater than $500,000
The thresholds for choosing providers required to submit utilization data are:
Medi-Cal paid claims volume equal to or greater than 5,000
Total Medi-Cal paid amount equal to or greater than $100,000
DHCS utilizes the data collected to develop the clinical laboratory reimbursement rates. Contingent on federal approval of SPA 20-0010, the following represents the steps taken in the determination of the average of the lowest rate.
DHCS uses the range of rates that fall between zero and one-hundred fifty percent of the calculated California specific Medicare rate.
These rates are then weighted based on the units billed to create an average.
The methodology is individually applied to each code meeting threshold requirements, excluding codes for which no third-party rate and/or utilization data was submitted, or if the services under that code were terminated or no longer a Medi-Cal benefit.
To ensure that requirements of the provisions of statute continue to be met, DHCS will collect third-party payer rate and utilization data every three years, beginning in 2019, from clinical laboratory or laboratory services providers. Rates are required to be calculated based on the prior year’s data and application of the methodology will be limited to those codes meeting either of the two thresholds. DHCS will continue to monitor the thresholds and methodology and make changes as necessary to comply with the law, access requirements, and account for other operational or programmatic issues.