PAMA Reporting Solutions For Labs

PAMA Reporting for Labs

The Protecting Access to Medicare Act of 2014 (PAMA) revised the payment methodology for clinical diagnostic laboratory tests paid under the Medicare Clinical Laboratory Fee Schedule (CLFS). Under PAMA, CMS will base 2025 clinical laboratory fee schedule payment rates on private payer rates as reported by applicable labs.

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CMS Further Delays PAMA

In December 2022, Section 4114 of Consolidated Appropriations Act 2023, delayed the PAMA data reporting period from 2023 to 2024. Applicable laboratories were given an additional year to report final payment data collected during the first six months of 2019.

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In November of 2018, CMS released its 2019 Physician Fee Schedule Final Rule, which contained new data collection criteria that will likely increase the number of applicable labs. These new criteria include the following changes to the applicable lab determination:

  • Medicare Advantage (Part C) payments are now excluded from the total Medicare revenue calculation used to determine whether a laboratory receives a majority of Medicare revenue under CLFS and/or MPFS (Medicare Physician Fee Schedule).

  • Hospital outreach laboratories that bill non-patients for their laboratory services (and meet the other criteria) are now considered applicable labs.

    • Quadax has updated our systems to incorporate these new criteria and is providing our clients tools to assist them in making the decision on whether they are an applicable lab subject to reporting. For applicable labs, we will obtain the final payment data from our systems and supply that data to our clients.

Quadax Resources

Final Data Files for PAMA Reporting (rev. November 2019) 
Preparing for PAMA Reporting (rev. Dec 2021) 
Prototype Data Files for PAMA Reporting (rev. November 2019) 
Quadax Data Files for PAMA FAQ (rev. April 2019) 
Quadax Ticket Selection Tree: How Tickets Will Be Selected for PAMA Reporting (rev. Dec 2021) 
Quadax Tools to Assist in the Determination of PAMA Applicable Lab (rev. Dec 2021)

CMS Resources

PAMA Regulations