Medical Billing and Coding Healthcare Blog

The Centers for Medicare & Medicaid Services (CMS) recently released an MLN Matters special edition article providing guidance for clinical laboratories about data reporting. The data reporting period opened on January 1.

Here are six things from the article for clinical laboratories to know about data reporting.

1. CMS has developed the online data collection system to assist laboratories in submitting data to CMS, which are due by March 31. A detailed user guide on how to access and use this system is available by clicking here.

2. Laboratories must designate both a Clinical Laboratory Fee Schedule (CLFS) submitter and CLFS certifier in the data collection system. These must be two different individuals. The CLFS submitter must be registered in Medicare's Provider Enrollment, Chain and Ownership System (PECOS) as a "user" or "authorized user" on the PECOS Medicare Enrollment forms (in other words, CLFS submitters must have their name appear within one of the following 855 application forms: A, B, C, I, R). The CLFS certifier does not need to be registered in PECOS.

A data reporting template is available here. Laboratories seeking to upload their data to the CLFS data collection system should use this template.

3. It is advisable to follow the formatting guidelines outlined in the user guide and on the data collection template. The CLFS data collection system will identify formatting errors in your file before you are able to certify the data and submit it. However, for large volumes of data, this process may take several hours to validate. Thus, those files with fewer formatting errors will be processed more efficiently.

4. It is advisable to use the CLFS Applicable Information HCPCS Codes file available here. The system will only accept HCPCS codes listed on this file.

5. The cleaner the file, the smoother the upload process will be.

6. If your laboratory expects to submit over 100,000 lines of data in the .csv template, first contact the CMS/CLFS helpdesk at This email address is being protected from spambots. You need JavaScript enabled to view it. .

Organizations looking for assistance with clinical laboratory billing can contact PGM Billing, a leading, national provider of lab billing services, by calling (877) 857-8981.

Rhode Island has become the latest state to take steps in an effort to address the ongoing challenge of surprise bills for medical services.

As the Providence Journal reports, state lawmakers are sponsoring legislation that would provide for a dispute resolution process for emergency services and surprise bills for medical services performed by nonparticipating (i.e., out-of-network) healthcare providers, regardless of whether the services are provided within or outside of the state.

The bill — H-5012 — is modeled after similar medical billing laws passed in Connecticut, New York and Florida. California is another state that has recently seen its lawmakers take action in this area, although some physicians have pushed back against it.

The Rhode Island bill's cosponsors include House Judiciary Chairman Cale P. Keable (D-Burrillville), Rep. Carol Hagan McEntee (South Kingstown), and Rep. Lauren H. Carson (D-Newport).

Craven, quoted in the Providence Journal report, stated, "My hope is that this legislation can ease the financial burden on Rhode Islanders when medical emergencies and surprises take place without sacrificing needed and potentially life-saving care."

What is Surprise Medical Billing?

A surprise medical bill — or balance billing — happens when a patient receives a bill from a doctor, hospital or other healthcare provider who is not part of the patient's health plan's network. Often, consumers do not know they are receiving care from out-of-network providers.

For example, a patient goes to an in-network hospital for emergency care and is treated by an out-of-network doctor. The doctor and the hospital each bill $1,000 for their services, and the health plan pays them each $400. The in-network hospital can only bill the patient for copays, deductibles, and coinsurance amounts. The doctor, however, may bill for the $600 that the health plan did not pay, as well as any copays, deductibles, and coinsurance.

As Brookings reports, "Over a dozen states have enacted important protections and federal and state officials have proposed additional remedies, but these efforts are incomplete, and they pursue a variety of different strategies."