​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 CodesCPT Code Description

Proposed

July 1, 2020 Rate

80305DRUG TEST PRSMV DIR OPT OBS              $9.98
82120AMINES VAGINAL FLUID QUAL $3.22
82172ASSAY OF APOLIPOPROTEIN $12.96
82270OCCULT BLOOD FECES $2.48
82962GLUCOSE BLOOD TEST $1.57
83020HEMOGLOBIN ELECTROPHORESIS $9.57
83050BLOOD METHEMOGLOBIN ASSAY $6.17
83789MASS SPECTROMETRY QUANT $16.28
84402ASSAY OF FREE TESTOSTERONE $4.45
84443ASSAY THYROID STIM HORMONE $11.20
84466ASSAY OF TRANSFERRIN $6.92
84480ASSAY TRIIODOTHYRONINE (T3) $8.82
84681ASSAY OF C-PEPTIDE $4.53
85025AUTOMATED HEMOGRAM $3.33
85046RETICYTE/HGB CONCENTRATE $3.56
85049AUTOMATED PLATELET COUNT $3.39
85060BLOOD SMEAR INTERPRETATION $5.25
85097BONE MARROW INTERPRETATION $34.85
85613RUSSELL VIPER VENOM DILUTED $5.80
85660RBC SICKLE CELL TEST $3.77
86038ANTINUCLEAR ANTIBODIES, RIA $6.47
86141C-REACTIVE PROTEIN HS $7.16
86147CARDIOLIPIN ANTIBODY EA IG $16.60
86300IMMUNOASSAY TUMOR CA 15-3 $16.14
86317IMMUNOASSAY INFECTIOUS AGENT $5.90
86334IMMUNOFIX E-PHORESIS SERUM $14.89
86359T CELLS TOTAL COUNT $29.54
86480TB TEST CELL IMMUN MEASURE $5.46
86635COCCIDIOIDES ANTIBODY $6.39
86677HELICOBACTER PYLORI ANTIBODY $12.45
86702HIV-2 ANTIBODY $10.77
86870RBC ANTIBODY IDENTIFICATION $11.32
86906BLOOD TYPING RH PHENOTYPE $4.76
87040BLOOD CULTURE FOR BACTERIA $8.25
87186MICROBE SUSCEPTIBLE MIC $5.77
87209SMEAR COMPLEX STAIN $3.10
87255GENET VIRUS ISOLATE HSV $8.00
87389HIV-1 AG W/HIV-1 & HIV-2 AB $14.04
87480CANDIDA DNA DIR PROBE $15.35
87486CHYLMD PNEUM DNA AMP PROBE               $23.14
87491CHYLMD TRACH DNA AMP PROBE $27.90
87502INFLUENZA DNA AMP PROBE $52.98
87512GARDNER VAG DNA QUANT $26.87
87536HIV-1 QUANT&REVRSE TRNSCRPJ $45.10
87631RESP VIRUS 3-5 TARGETS                   $45.00
87633RESP VIRUS 12-25 TARGETS $139.79
87653STREP B DNA AMP PROBE $24.68
87661TRICHOMONAS VAGINALIS AMPLIF $26.27
87806HIV ANTIGEN W/HIV ANTIBODIES             $17.12
88104CYTOPATH FL NONGYN SMEARS $10.39
88108CYTOPATH CONCENTRATE TECH $22.67
88112CYTOPATH CELL ENHANCE TECH $59.93
88172CYTP DX EVAL FNA 1ST EA SITE             $25.58
88184FLOWCYTOMETRY/ TC 1 MARKER $32.67
88189FLOWCYTOMETRY/READ 16 & > $30.58
88302TISSUE EXAM BY PATHOLOGIST $18.02
88307TISSUE EXAM BY PATHOLOGIST $76.30
88312SPECIAL STAINS GROUP 1 $26.78
88350IMMUNOFLUOR ANTB ADDL STAIN              $63.83
84311SPECTROPHOTOMETRY                        $6.12
G0482DRUG TEST DEF 15-21 CLASSES              $126.22
G0483DRUG TEST DEF 22+ CLASSES                $160.47

 

Background

In accordance with Assembly Bill (AB) 1494 (Committee on Budget), the DHCS is required to:

  • Develop a new rate setting methodology for clinical laboratory or laboratory services based on the average of the lowest prices other third-party payers are paying for similar services.

    • Effective July 1, 2015, the new rate methodology is implemented under approved SPA 15-015

  • 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).

    • The ten percent payment reduction is implemented under approved SPA 12-028

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 

Rate Methodology

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.

  1. These rates are then weighted based on the units billed to create an average.

  2. 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.

Contact DHCS

Questions or comments can be submitted to the DHCS Clinical Laboratory email box: labcomments@dhcs.ca.gov.  

Legislation

Last modified date: 7/23/2020 12:52 PM