CMS/CLIA Compliant Laboratory Services

To ensure high laboratory testing standards, Medi-Cal is incorporating select Centers for Medicare & Medicaid Services (CMS) clinical laboratory billing policies in the provider manual, including the following:

Part of ensuring lab-test quality is matching a provider with a category of service. The category of service helps identify the labs skill level, which further helps define the types of lab tests the lab may perform and be reimbursed for.

Based on CMS information, Medi-Cal will allow reimbursement for any of the following laboratory tests (CPT-4 codes) when billed by providers in any of the three categories of service (bulleted items).

• Clinical Laboratory Improvement Amendments of 1988 (CLIA) Waived Tests
• Provider Performed Microscopy
• CLIA Accredited Laboratory/Pathology Services

Claims for these tests/codes will be denied when submitted by providers in categories of service other than those bulleted above.

Claims denied for these procedure codes retroactive to dates of service on or after April 1, 2008 will be automatically reprocessed. Providers need take no action.