CMS Lab Fee Schedule

The CMS Lab Fee Schedule tool lets you calculate reimbursements based on the national Medicare lab fee schedule.

The CMS Lab Fee Schedule tool allows you to calculate reimbursements based on a national Medicare lab fee schedule and define an effective date, code range, or procedure lookup table for each percentage. If you enter multiple percentage lines, the lines are calculated from top to bottom. A procedure code matches an entry in a lookup table according to standard matching rules. For more information, refer to Reimbursement Tools.
To override the lab fees associated with the service location’s zip code, select the Override zip code carrier/locality lookup check box. You can specify a carrier and locality number, or choose to reprice at the national limit, the floor limit, or with median lab fees.

The following table describes the fields on the CMS Lab Fee Schedule reimbursement tool.

Field	Description
+	Clicking the plus (+) adds another percentage line to the tool and lets you define a fee schedule and place of service.
-	Clicking the minus (-) sign removes that percentage line from the reimbursement tool.
Carrier	The 5-digit identification number for the carrier.
Codes From	The beginning value for your code range. This field is inclusive, that is if you enter a Code From value of 90000, your range begins with code 90000, not 90001.
Codes To	The ending value for your code range. This field is inclusive, that is if you enter a Code To value of 90000, your range ends with code 90000, not 8999.
Consume Resources	Indicates whether units are consumed. Selecting this check box consumes resources. If you do not select this check box, resources are not consumed.
Effective Date	The effective service date of the CMS Lab Fee Schedule you want to use.
Locality	The 2-digit identification number for the locality.
Or	A list that lets you select a specific procedure lookup table as a code filter. Only procedures found within this table will be priced.
Override zip code carrier/locality lookup	Override the lab fees associated with the service location’s zip code. Note: With professional facilities, the override is effective with invoices prior 10/01/2021.
Percentage	Sets the percent of the base amount in the fee schedule at which the procedure code is reimbursed. For example, if you enter 75, all procedures that match the code range or procedure lookup table and have not been repriced by another tool are repriced at 75% of amount listed in the fee schedule.
Specify carrier locality	Select this option to specify a set of lab fees.
Use floor	Reimburses the lowest fees allowed by Medicare.
Use mid point	Reimburses median Medicare lab fees.
Use national limit	Reimburses the highest fees allowed by Medicare.
When codes are found in multiple Fee Schedules, pay	Indicates what to do if a particular procedure code is found in multiple CMS Lab Fee Schedules. You can select First Occurrence to use the first (top) CMS Lab Fee Schedule listed in the tool, Highest Reimbursement, or Lowest Reimbursement to use the CMS Lab Fee Schedule that returns the highest or lowest reimbursement of those listed in the tool.