and Human Services
Health Care Financing
SUBJECT: Cervical or Vaginal Smear Tests (Pap Smears) Included
in Calendar Year (CY) 2000 Clinical Diagnostic Laboratory Fee
This program memorandum (PM) provides instructions for
implementing §224 of the Balanced Budget Refinement Act (BBRA)
(Public Law 106-113) which was enacted November 29, 1999.
Specifically, §224 of the BBRA (Increase in Reimbursement for Pap
Smears) revises §1833(h) of the Social Security Act (the Act) to
modify reimbursement for Pap Smears paid under the CY 2000 clinical
diagnostic laboratory fee schedule.
Section 1833(h) directs that the Medicare Part B payment for
conventional Pap smears is determined by a fee schedule established
on a local (regional, statewide, or carrier service area) basis not
to exceed a national limit of 74 percent of the median of all the
local fee schedules established. This statute, in addition to other
limiting factors, results in a national limit amount of $7.15 for CY
Congress has now established a national minimum payment amount
for diagnostic or screening Pap smear laboratory tests (including
all cervical cancer screening technologies that have been approved
by the Food and Drug Administration as a primary screening method
for detection of cervical cancer) of not less than $14.60 for dates
of service in the year 2000. This PM supplements PM AB-99-84, dated
November 1999, in order to implement the provision effective January
1, 2000. If the pricing amount for the following codes is less than
$14.60 for CY 2000, it must be increased to $14.60. Standard Systems
must be modified to assure payment of at least $14.60 for dates of
service 1/1/2000 and later. Do not search for previously adjudicated
claims, however, timely filed claims may be reprocessed if brought
to your attention.
In addition, §1833(a)(1)(D) of the Act provides that payment will
be the least of the local fee schedule, the National Limitation
Amount, or the actual charge billed for the test. Therefore, the
payment shall not exceed the actual charge where it is less than
$14.60. Attachments B and C from PM AB-99-84 (November 1999)
continue to apply to the following gap-fill codes: 88142, 88143,
88144, 88145, 88147, 88148, G0123, G0143, G0144, G0145, G0147, and
G0148. Report the gap-fill amounts by May 5, 2000 to the RO. The
gap-fill amount reported to the RO can be any amount (i.e. less than
$14.60). The actual payment must be either the lesser of: actual
charges, the gap-filled amount if it is higher than $14.60 or $14.60
if the gap-filled amount is less than $14.60 (Please see examples on
table 1 of page 2). In subsequent years, HCFA will update the
national minimum payment amount in accordance with the statute and
compute the pricing for Pap smear codes. The affected HCFA Common
Procedure Coding System (HCPCS) codes on the clinical diagnostic
laboratory fee schedule are G0123, G0143, G0144, G0145, G0147,
G0148, P3000, 88142, 88143, 88144, 88145, 88147, 88148, 88150,
88152, 88153, 88154, 88164, 88165, 88166, and 88167.
NOTE: Public Law 106-113 also included §223 that states: "The
Secretary of Health and Human Services may not use, or permit fiscal
intermediaries or carriers to use, the inherent reasonableness
authority provided under section 1842(b)(8) of the Act until after
the Comptroller General of the United States releases a report
pursuant to the request for such a report made on March 1, 1999,
regarding the impact of the Secretary's, fiscal intermediaries', and
carriers' use of such authority." Therefore, HCFA has suspended its
activities related to the inherent reasonableness authority for the
examination of the payment amounts for Pap smears.
The effective date for this PM is January 1, 2000.
The implementation date for this PM is January 17, 2000.
These instructions should be implemented within your current
For questions regarding this document, contact Brett James on
This PM may be discarded after December 31, 2000.
Source: Health Care Financing
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