Downcoded
September 22, 20264 min readFree

The 118 Lab Codes Medicare Still Hasn't Priced

CMS posted the October clinical lab fee schedule at 8:08 this morning, nine days before it starts paying. It adds 39 codes at $0.00 and changes the price of nothing, which makes 118 codes on the schedule that carry a local pricing indicator and no national rate. All 32 of the ones that arrived on January 1 are still sitting there.

At 8:08 this morning CMS replaced the July clinical lab fee schedule with the October one. The zip went up on cms.gov with a last-modified stamp of 12:08:26 GMT, and the rates inside it start paying on October 1.

Nine days of lead time.

The October file has 2,243 rows, and 2,125 of them carry a national payment rate.

The other 118 carry a pricing indicator of L and a payment rate of 00000.00. That second number is the only thing on this fee schedule that has moved all year (chart below).

What the October update actually updates

We keyed all four 2026 quarterly files on HCPCS plus modifier and diffed them against each other. The result is close to nothing.

  • January to April: 17 codes added, none removed, zero payment rates changed.
  • April to July: 31 added, 4 removed, zero payment rates changed.
  • July to October: 40 added, 3 removed, zero payment rates changed.

Not one code that appears in two consecutive files moved by a cent, in either direction, across three quarterly updates. No code switched between national and local pricing either. That flatness is on purpose: CR 14569 restates that there is no phased-in PAMA reduction in CY2026, and that the 15% annual floor on reductions does not start until January 1, 2027. So the national column sits still and the quarterly file does one job, which is adding codes.

Of the 40 codes added in October, 39 are local-priced at $0.00. They run 0660U through 0698U, a contiguous block of proprietary laboratory analyses, every one of them effective October 1.

The fortieth is 0442U with a QW modifier at $41.38, the CLIA-waived version of a code already on the schedule.

Three codes came off, and all three had real money on them: 0556U at $142.63, 0557U at $262.99, and 0585U, a 521-gene solid tumor cell-free DNA panel, at $2,919.60.

The January cohort is still in the file

Here's the part worth your attention. Thirty-two codes arrived on the January 1 file with the local indicator and no rate.

Nine months and three quarterly updates later, all 32 are still in the October file, and zero of them have been nationally priced.

The grey block in every bar of that chart is the previous bar's entire total. Nothing has ever left this list in 2026.

A backlog works itself down. This one runs one way: 32, then 49, then 79, then 118.

What a local indicator costs you at the desk

CR 14569 is direct about the mechanics. New codes "are contractor-priced (where applicable) until they are nationally priced and undergo the CLFS annual payment determination process," and "MACs shall only price PLA codes for laboratories within their jurisdiction."

Read that second clause again if you run a lab with sites in more than one MAC footprint. The same PLA code is a separate pricing decision in every jurisdiction you touch, made by a contractor under no published deadline, with no national number to appeal back to.

Three practical consequences:

  • Your chargemaster has no anchor. There is no CMS rate to set expected reimbursement against, so the code lands in your variance reports as an outlier every time it bills.
  • Your commercial contracts quietly break. Any rate defined as a percentage of the Medicare clinical lab fee schedule resolves to a percentage of $0.00 for these 118 codes, and whatever your payer does next is not in the contract.
  • The appeal has no benchmark. A denial or an underpayment on a locally priced code gets argued against your MAC's own determination, which may exist only as a number in an adjudication system.

Final Thoughts

There is exactly one exit from this list, and it is the annual payment determination process. That machinery has already run most of its CY2027 cycle in public: the CLFS annual public meeting was held June 10, and the Medicare Advisory Panel on Clinical Diagnostic Laboratory Tests met last Tuesday and Wednesday, September 15 and 16, to hear recommendations on crosswalking and gapfilling the codes CMS has no reported private payer data for. Preliminary determinations come out of that, then comment, then final rates on a January file.

Your MAC will price the code eventually. The open question for anyone billing out of the 0600U range is whether you learn the number from a remittance advice or from a determination you read while it was still a draft.

So pull the October file and filter column five to L. For most practices the count of those 118 you actually bill is zero, and this is a footnote. For a molecular lab it is a payer-mix problem with nine months of precedent already behind it.

Thanks for reading.