$'''''''"'~ DEPARTMENT OF HEALTH AND HUMAN SERVICES 

! ~<?- OFFICE OF INSPECTOR GENERAL "O~+~+.(;~ .... 	 WASHlNGTON, DC 2020]

JUN t 2 2012 

TO: 	 Marilyn Tavenner 

Acting Admini strator 

Centers for Medicare & Medicaid Services 

FROM: Stuart Wright 

Deputy Inspector General 

for Evaluation and Inspections 

SUBJECT: 	 Memorandum Report: Coverage and Payment for Genetic Laboratory 

Tests, OEI-07-11-000 11 

This memorandum report provides the results of surveys sent to State Medicaid and 

Federal Employee Health Benefit (FEHB) programs and interviews with Veterans Health 

Administration (VHA) staff regarding coverage and payment for genetic laboratory tests. 

Centers for Medicare & Medicaid Services (CMS) officials requested this infonnation at 

the start of our study entitled Payments for Laboratory Tests: Comparing Medicare, 

State Medicaid, and Federal Employees Health Benefits Programs (OEI-07-11-00010). 

This infonnation is provided to assist CMS in its efforts to establish payment rates for 

genetic tests. CMS has scheduled its annual laboratory public meeting for July 16,2012. 

At this meeting, 101 new genetic test codes for which no Medicare payment rates exist 

will be discussed. 

SUMMARY 

The Office of Inspector General (OIG) is currently conducting an evaluation entitled 

Paymentsfor Laboratory Tests: Comparing Medicare, State Medicaid, and Federal 

Employees Health Benefits Programs (OEI-07-11-00010). The objectives of that 

evaluation are to determine (I) how the methods for establishing Medicare laboratory test 

payment rates vary from State Medicaid and FEHB programs, and (2) the extent to which 

2011 Medicare payment rates for 20 high-volume and/or high-expenditure laboratory 

tests vary from State Medicaid and FEHB plans. During a meeting on June 29, 2011, 

eMS officials informed us that, in addition to high-volume and high-expenditure 

laboratory tests, a collection of pricing data for genetic tests from other health care 

insurers would assist CMS in establishing payment rates for the 101 new genetic test 

codes in 2012. 

OEI-07-11 -00011 Coverage and Payment for Genetic Laboratory Tests 
 

 

 

Page 2 – Marilyn Tavenner 

To answer the objectives of the earlier evaluation, we surveyed State Medicaid and 

FEHB plan staff to determine payment rates for each State and FEHB plan and to 

determine how their laboratory test payment rates were established. To respond to CMS 

officials’ requests for similar information for genetic tests, we (1) surveyed State 

Medicaid and FEHB plan staff and interviewed VHA staff about their coverage policy 

and establishment of payment rates, and (2) obtained 2011 payment rates for selected 

genetic tests by name and by Common Procedural Terminology (CPT) code from each of 

the health care insurers we surveyed. The payment rate information for genetic tests by 

CPT code is important because these codes are the basis underlying 101 new genetic test 

CPT codes. We are providing the results of the surveys and interviews in this 

memorandum for CMS’s use in informing Medicare coverage and payment policies for 

genetic tests. 

BACKGROUND 

Clinical diagnostic laboratory tests (lab tests) are performed on specimens taken from the 

human body. Lab tests provide information integral to preventing, diagnosing, and 

treating disease. Most lab tests are performed in hospitals, physicians’ offices, or 

independent laboratories. Genetic testing is the use of a lab test to look for genetic 

variations associated with a disease.1

 Genetic tests can be used to predict, prevent, and 

inform the treatment of diseases. 

As with any new medical technology, genetic tests face challenges as they are integrated 

into the health care system, such as health care insurers’ decisions to provide coverage 

and establish payment rates for these services. Although genetic testing has been 

performed for more than 20 years, these decisions are still evolving. 

Medicare Coverage of Genetic Tests 

The Social Security Act provides that no Medicare payment may be made for expenses 

incurred for items or services that are not reasonable and necessary for the diagnosis or 

treatment of illness or injury or to improve the functioning of a malformed body 

member.2

 Consistent with this, Medicare does not pay for preventive screening tests 

except for those specifically authorized by statute (e.g., prostate-specific antigen test). 

Since CMS considers predictive tests to be screening tests, genetic tests for this purpose 

are not covered by Medicare. However, genetic tests used to diagnose or determine 

treatment in the presence of signs and symptoms of disease can be covered by Medicare.3 

A common use of genetic tests in the Medicare population is to assist in determining 

1 National Human Genome Research Institute, National Institutes of Health. Accessed at 

http://www.genome.gov on January 25, 2012.
 2 Social Security Act § 1862(a)(1)(A).
 3 Secretary’s Advisory Committee on Genetics, Health, and Society, Coverage and Reimbursement of Genetic
 

Tests and Services, February 2006, p. 30. Accessed at http://oba.od.nih.gov/oba/sacghs/reports/CR_report.pdf on 

January 25, 2012.
 

OEI-07-11-00011 Coverage and Payment for Genetic Laboratory Tests 
 

 

 

 

Page 3 – Marilyn Tavenner 

cancer treatment. Genetic tests can be used to predict optimal chemotherapy regimens 

and avoid exposing patients to ineffective or overly toxic regimens.4 

Medicare uses a combination of national and local coverage determinations for making 

coverage decisions for genetic tests. National coverage determinations (NCD) are made 

at the Federal level and apply to all Medicare beneficiaries and Medicare administrative 

contractors (MAC). Currently, only two NCDs related to genetic tests have been 

established: (1) testing to predict patient responsiveness to the drug warfarin sodium, and 

(2) cytogenetic studies.5

 MACs make local coverage determinations (LCD), which apply 

only to beneficiaries in the contractor’s jurisdiction. Of the nearly 9,000 LCDs, only 

11 are related to genetic tests. For example, one MAC covers BRCA1 and BRCA2 

genetic testing for beneficiaries who meet certain criteria.6 

Medicare Payment for Genetic Tests 

The Clinical Laboratory Fee Schedule. The Deficit Reduction Act of 1984 (DRA) 

mandated that payment rates be established for lab tests on a regional, statewide, or 

carrier basis.7 The DRA also mandated that the Consumer Price Index for All Urban 

Consumers be used annually to adjust rates for inflation. Beginning July 1, 1984, each 

carrier (i.e., Medicare Part B claims payment contractor) established its own payment 

rates based on the prevailing charges for lab tests in its locality. These payment rates are 

collectively known as the Clinical Laboratory Fee Schedule (CLFS). 

CMS publishes an updated CLFS at least annually containing payment rates based on the 

57 jurisdictions of the former Medicare Part B claims payment carriers. Although 

15 MACs have largely replaced the Medicare Part B claims payment carriers, MACs 

continue to administer the same payment policies created by the 57 carriers. The 

2011 CLFS contains each carrier’s rate for 1,140 unique lab tests identified by CPT code, 

including some genetic tests.8, 9 

Annual Laboratory Meeting. In accordance with section 1833(h)(8)(B) of the Social 

Security Act, CMS conducts an annual public meeting on payment rate recommendations 

for new lab test codes developed by the AMA’s CPT Editorial Panel. The meeting is 

intended to provide input on the nature of the new test codes and receive 

recommendations concerning the determination of payment rates. In 2011, CMS 

4 National Human Genome Research Institute, National Institutes of Health. Accessed at 

http://www.genome.gov on January 25, 2012.
 5 CMS, Medicare National Coverage Determinations Manual [Internet-Only Manual], Pub.100-03, ch. 1, 

§§ 90.1 and 190.3. Accessed at http://www.cms.gov/Manuals/IOM/list.asp on January 25, 2012.
 6 Noridian Administrative Services, LCD ID Number L24308. Accessed at http://www.cms.gov/medicarecoverage-database/license/ on April 25, 2012.

7 Deficit Reduction Act of 1984, P.L. 98-369, § 2303(d), Social Security Act, § 1833(h).
 8 CPT, a numeric coding system maintained by the American Medical Association (AMA), is a uniform coding 

system consisting of descriptive terms and identifying codes that are used primarily to identify medical services 

and procedures furnished by physicians and other health care professionals. CPTs make up one part of the 

Healthcare Common Procedure Coding System (HCPCS) code set.

9 CMS, 2011 Clinical Laboratory Fee Schedule. Accessed at https://www.cms.gov/ClinicalLabFeeSched on 

January 13, 2012.
 

OEI-07-11-00011 Coverage and Payment for Genetic Laboratory Tests 
 

 

 

 

 

   

  

Page 4 – Marilyn Tavenner 

followed the public meeting with an information session on 101 new CPT codes for 

genetic tests that CMS plans to assign payment rates to in 2012. The 2012 meeting is 

scheduled to be held on July 16. 

Payment Methods for Genetic Tests 

In 1992, AMA added a new section of CPT codes for genetic tests. These codes focused 

on the laboratory procedure(s) used for a test rather than the substance or chemical 

analyzed. This coding system was developed to accommodate rapidly developing 

technologies. However, as stated in a pathology journal article, some health insurers 

expressed concern with this method because it led to a lack of standardization and a lack 

of specificity as to the test performed, which is discussed in greater detail below.10 

Stacking. Until 2012, Medicare did not use single CPT codes for genetic tests as it does 

for other lab tests (e.g., 81003-urinalysis automated without microscopy, 

85610-prothrombin time). For nearly a decade, Medicare contractors, as well as other 

health care insurers, have used a reimbursement method referred to as “stacking.” 

Stacking is the use of multiple generic molecular diagnostic CPT codes (83890–83914) to 

form the basis of reimbursement for a single genetic test.11 Payment rates for many of 

these individual CPT codes are listed on the CLFS. Different laboratories may use 

differing procedures to perform the same lab test; therefore, they use differing quantities 

of CPT codes to file claims for the tests. As shown in Table 1, a cystic fibrosis profile at 

one laboratory might be coded with a total of 29 units of 5 different CPT codes, while the 

same test from another laboratory might be coded with a total of 89 units of 6 different 

CPT codes.12 

10 Anne Paxton, Molecular CPT Codes Topple Old “Stacking” Codes, CAP Today, April 2011. Accessed at 

http://www.cap.org on January 13, 2012. 

11 Ibid. 

12 L. Joan Logue, Genetic Testing Coverage and Reimbursement: A Provider’s Dilemma, Clinical Leadership 

& Management Review, November/December 2003, pp. 346–350. 

OEI-07-11-00011 Coverage and Payment for Genetic Laboratory Tests 
 

 

Page 5 – Marilyn Tavenner 

Table 1: Example of a Cystic Fibrosis Profile Offered by Two Laboratories 

Lab A Cystic Fibrosis 32 Mutations 

Code Number of Units Medicare CLFS Rate 

83890 1 $5.60 

83894 1 $5.60 

83896 25 $140.00 

83901 1 $23.42 

83912 1 $5.60

 Total 29 $180.22 

Lab B Cystic Fibrosis 32 Mutations 

Code Number of Units Medicare CLFS Rate 

83890 1 $5.60 

83892 1 $5.60 

83894 1 $5.60 

83896 84 $470.40 

83901 1 $23.42 

83912 1 $5.60

 Total 89 $516.22 

Note: The source of this example erroneously listed the Medicare CLFS rate as $54.60 for 

83912 for Lab B.
 

Source: L. Joan Logue, Genetic Testing Coverage and Reimbursement: A Provider’s
 

Dilemma, Clinical Leadership & Management Review, November/December 2003, 

pp. 346–350.
 

Medicare rules do not address the quantity or configuration of stacking codes for genetic 

tests. The lack of standardization results in wide variation in payment amounts for the 

same genetic test. Another shortcoming of this reimbursement method is that it does not 

provide specificity to the payer as to what was tested because the same set of codes is 

used in a variety of genetic test types. 

Effective January 1, 2012, CMS instructed MACs to include in claims for genetic tests 

1 of the 101 new single CPT codes representing a genetic test as well as the underlying 

stacked codes.13 The new, single CPT codes do not yet have a payment amount assigned 

to them. For now, claims will be paid according to the payment rates assigned to the 

underlying stacked codes. This new claim payment procedure may provide more 

information to CMS on the quantities of stacked codes underlying a single genetic test 

and the quantities and types of genetic tests provided to Medicare beneficiaries. 

However, it does not resolve the issue of variation in payment amounts. 

S Codes. Although most State Medicaid program and commercial health insurers 

(e.g., FEHB plans) use the stacking method of reimbursement, some alternatively use 

Healthcare Common Procedure Coding System (HCPCS) “S” codes. S codes are 

assigned by the HCPCS Workgroup at the request of commercial insurers. They are not 

reportable to Medicare. In contrast to stacking, a single S code captures all of the 

13 CMS, Recurring Update Notification, Pub. No. 100-04, Transmittal 2365, Change Request 7654, dated 

December 9, 2011. 

OEI-07-11-00011 Coverage and Payment for Genetic Laboratory Tests 
 

 

 

Page 6 – Marilyn Tavenner 

components of the genetic test. One example of an S code is “S3818-complete gene 

sequence analysis of the BRCA1 gene.”

14 

Medicare’s Role in Establishing the Payment Rates of Other Health Care Insurers 

As the largest health insurer in the United States, Medicare has great influence on the 

actions of other health care insurers. In fact, section 1903(i)(7) of the Social Security Act 

prohibits State Medicaid program payments for lab tests that exceed the Medicare 

payment amount. In addition, private health insurance plans closely monitor Medicare’s 

coverage and reimbursement decisions.15 Therefore, it is important that CMS accurately 

formulate the reimbursement rates for genetic tests. 

VHA 

Unlike other Federal health insurance programs (e.g., Medicare), VHA operates its own 

medical centers and community-based outpatient clinics and permits more than 

53,000 independent licensed health care practitioners to work within those facilities. 

VHA is the largest integrated health care system in the United States, providing health 

care to approximately 8.3 million veterans.16 In 2006, the Department of Veterans 

Affairs launched the Genomic Medicine Program. The goals of the program are: (1) to 

examine the potential of emerging genomic technologies, (2) to optimize medical care for 

veterans, and (3) to enhance the development of tests and treatments for relevant 

diseases. 

METHODOLOGY 

Surveys 

From August through October 2011, we conducted an electronic survey of 50 State 

Medicaid programs and 3 FEHB plans that pay for lab tests on a fee-for-service basis.17 

We asked questions about their coverage policy for genetic laboratory tests; the methods 

established for payment of claims for genetic laboratory tests; and the payment rates in 

effect for the period January 1 through March 31, 2011, for 16 genetic tests by CPT 

stacking code and 16 selected genetic tests by name. The 16 genetic tests by stacking 

codes were selected because they are included in the set of stacking codes underlying the 

101 new single genetic test codes. Appendix A contains lists of tests reviewed. 

We received completed surveys from all 50 State Medicaid programs and 3 FEHB plans. 

The three fee-for-service FEHB plans provide coverage to 90 percent of fee-for-service 

enrollees in the FEHB program. Each of these national plans provides services through 

local plans and networks. Within a single national plan, local plans and networks may 

14 AMA, HCPCS Level II Professional Edition, 2011, p. 313.

15 Secretary’s Advisory Committee on Genetics, Health, and Society, Coverage and Reimbursement of Genetic
 

Tests and Services, February 2006, p. 25. Accessed at http://oba.od.nih.gov/oba/sacghs/reports/CR_report.pdf on 

January 25, 2012. 

16 Accessed at http://www.va.gov/health/aboutVHA.asp on March 20, 2012.
 17 Staff from the Tennessee Medicaid program stated that 100 percent of recipients are enrolled in managed care 

plans; therefore, Tennessee does not pay for any lab tests on a fee-for-service basis. We did not include the 

Tennessee Medicaid program in our data collection. We included the District of Columbia, for a total of 50 State 

Medicaid programs.
 

OEI-07-11-00011 Coverage and Payment for Genetic Laboratory Tests 
 

 

Page 7 – Marilyn Tavenner 

have differing coverage policies and payment rates. While FEHB plans provided 

payment rates representing all of their local plans and networks, they did not provide 

coverage policy and payment methods for each individual plan or network. In total, we 

received surveys from 29 of 58 FEHB local plans and/or networks. 

Structured Interviews 

We conducted structured interviews with both national and local VHA staff. We asked 

questions regarding coverage policy and payment for genetic tests. We accessed VHA 

lab test payment rates on publicly available Web sites. As previously stated, unlike 

Medicare, Medicaid, and FEHB, VHA operates its own medical centers and privileges 

and credentials its own providers to serve its members. Therefore, we used a different 

data collection method with VHA than with the other health care insurers. 

Standards 

This study was conducted in accordance with the Quality Standards for Inspection and 

Evaluation issued by the Council of the Inspectors General on Integrity and Efficiency. 

RESULTS 

Below, we present information provided to us through surveys and interviews in the areas 

of coverage policies, payment methods, and payment rates. 

Coverage Policies for Genetic Tests 

We asked officials from each State Medicaid program, each FEHB plan, and VHA to 

describe their organizations’ coverage policy for genetic tests. 

State Medicaid Programs. Officials from all but one State Medicaid program described 

some level of coverage for genetic tests. Officials from New Mexico stated that genetic 

tests are generally not covered. Officials from 17 States stated that although genetic tests 

are covered, their States have no specific policy addressing them. Officials from the 

remainder of States described a variety of factors that influenced coverage decisions, 

including performing genetic tests for the purpose of either diagnosis of a disease or 

treatment (nine States), requiring prior authorization for either all or certain types of 

genetic tests (eight States), and considering coverage on a case-by-case basis (six States). 

The Alabama Medicaid program volunteered that it is working with a consultant to 

develop a coverage policy. 

FEHB Plans. Officials from each of the three national FEHB plans described some level 

of coverage for genetic tests. At the time of our data collection, officials from one 

national plan reported that, in the past, coverage for specific genetic tests was evaluated 

for medical necessity on an individual basis. However, the plan had recently experienced 

increased demand for genetic tests, so plan officials were working on a more robust 

policy. Of the 29 local and network plans, 4 reported that coverage policies are 

test-specific and 3 required preauthorization for genetic tests. 

OEI-07-11-00011 Coverage and Payment for Genetic Laboratory Tests 
 

 

 

 

Page 8 – Marilyn Tavenner 

VHA. VHA places a strong emphasis on medical coverage decisionmaking by a patient’s 

clinician(s). According to regulations found at 38 CFR 17.38(b), care referred to in the 

“medical benefits package”18 will be provided to individuals only if it is determined by 

appropriate health care professionals that the care is needed to promote, preserve, or 

restore the health of the individual and is in accord with generally accepted standards of 

medical practice. VHA officials reported to us that tests used to make a primary 

diagnosis or to modify treatment are easily justified. A medical center’s pathologist 

serves as a gatekeeper to evaluate the test ordered by a clinician against clinical 

requirements. 

Payment Methods 

State Medicaid Programs. Thirty-nine State Medicaid programs reported that they paid 

for genetic tests using only the stacking method. Two States reported that they paid for 

genetic tests only by test name (e.g., by S code). Eight States reported using a 

combination of these methods. One State reported that it did not cover genetic tests, and 

therefore did not report a payment method. 

Of the 47 State Medicaid programs that reported paying for genetic tests using the 

stacking method, only Iowa determined a maximum quantity and combination of stacked 

codes that it would reimburse for a given test. Iowa reported the maximum number and 

combination of stacked codes for 6 of the 16 genetic tests on our survey. These 

combinations are shown in Appendix B. Minnesota reported the set of stacked codes it 

allowed for certain tests, but did not specify a maximum quantity for each of these codes. 

These combinations are shown in Appendix C. 

FEHB Plans. One national FEHB plan reported that it did not approve many genetic 

tests. This plan noted that some tests do not have CPT codes associated with them; the 

plan prices these tests based on available fee data. The plan is in the process of 

developing a pricing strategy for an expected increase in usage of genetic tests. Another 

national FEHB plan responded that payment for a genetic test is based on claim 

information and contractual rates. The remaining national FEHB plan noted that 

responses varied among the local plans, with some plans using stacked CPT codes and 

some plans paying by test name. 

VHA. Some VHA medical center laboratories can perform certain genetic tests onsite, 

but the majority of genetic test specimens are sent to reference laboratories for 

processing. VHA has national contracts with four reference laboratories. The contracts 

contain a list price for each lab test offered. In addition, VHA’s regionally based service 

networks, or individual medical centers within those networks, may negotiate prices 

lower than contract list prices based on volume. Because genetic test volume has been 

low, staff from one medical center reported that in most cases, the volume has not been 

large enough to justify negotiating prices lower than list prices. 

18 The definition of “medical benefits package” can be found in 38 CFR § 17.38. It includes services such as 

outpatient, hospital, and extended care. 

OEI-07-11-00011 Coverage and Payment for Genetic Laboratory Tests 
 

 

 

 

Page 9 – Marilyn Tavenner 

Payment Rates 

We asked officials from each State Medicaid program and FEHB plan to provide us with 

the payment rates in effect for January 1 through March 31, 2011, for 16 genetic tests by 

CPT stacking code and 16 selected genetic tests by name. State Medicaid programs 

provided their fee schedules for lab tests, representing the maximum payment rate 

allowed for each test. (For actual claims, providers could have billed for less than the fee 

schedule amount.) FEHB plans provided us with median claim payment amounts for lab 

tests performed during the period of our review. 

State Medicaid Programs. Appendix D compares State Medicaid program fee schedule 

rates for 16 genetic tests by CPT stacking codes with Medicare CLFS payment rates. 

Eight State Medicaid programs provided payment rates by test name. These prices are 

shown in Appendix E. We note great variation in test prices; for example, the payment 

rate for a BRCA1 gene analysis ranged from $1,000 in Pennsylvania to nearly $4,500 in 

Iowa. 

FEHB Plans. Appendix D compares FEHB plan median payment rates for 16 genetic 

tests by CPT stacking code with Medicare CLFS payment rates. One national FEHB 

plan provided prices for genetic tests by name. These prices are shown in Appendix F. If 

the FEHB plan did not pay a lab test claim for a particular test, no price is listed. Similar 

to State Medicaid programs, FEHB plans reported variation in tests prices. For example, 

the AlloMap ranged from $2 to $3,658. Other tests had less price variation, such as the 

Pathwork Tissue of Origin, which ranged from $5 to $38. One FEHB plan official noted 

that the variation in payment rates is likely due to low test volume and services provided 

by nonpreferred provider organizations. The plan is reviewing instances in which its 

payment rates are higher than other insurers.’ 

VHA. VHA has national contracts with four laboratories: ARUP Laboratories, 

Laboratory Corporation of America, Quest Diagnostics Nichols Institute, and Sonora 

Quest Laboratories, LLC. Only one contractor lists prices by CPT code. We have not 

included contract list prices in this memorandum because this information can be located 

on the General Services Administration Web site.19 

CONCLUSION 

We have provided this information for CMS’s use in setting Medicare coverage and 

payment policies for genetic tests. Because State Medicaid programs and private health 

insurance plans closely monitor Medicare’s coverage and reimbursement decisions, 

CMS’s formulation of reimbursement rates for genetic tests may be useful to them. As 

one official from a State Medicaid program remarked, “Additional guidance from CMS 

on genetic testing would be very helpful. We have struggled with payment of such tests 

for the last couple of years.” 

19 General Services Administration, Medical Laboratory Testing and Analysis Services, Schedule 621 II. 

Accessed at http://www.gsaelibrary.gsa.gov on February 24, 2012. 

OEI-07-11-00011 Coverage and Payment for Genetic Laboratory Tests 
 

Page 10 – Marilyn Tavenner 

This report is being issued directly in final form because it contains no recommendations. 

If you have comments or questions about this report, please provide them within 60 days. 

Please refer to report number OEI-07-11-00011 in all correspondence. 

OEI-07-11-00011 Coverage and Payment for Genetic Laboratory Tests 
 

 

Page 11 – Marilyn Tavenner 

APPENDIX A 

Genetic Tests Included in Review 

Genetic Tests by Current Procedural Terminology Stacking Code Included in Review 

Code Description 

83890 Molecular diagnostics; molecular isolation or extraction, each nucleic acid type 

83891 Molecular diagnostics; isolation or extraction of highly purified nucleic acid, 

each nucleic acid type 

83892 Molecular diagnostics; enzymatic digestion, each enzyme treatment 

83894 Molecular diagnostics; separation by gel electrophoresis, each nucleic acid 

preparation 

83896 Molecular diagnostics; each nucleic acid probe 

83897 Molecular diagnostics; nucleic acid transfer, each nucleic acid preparation 

83898 Molecular diagnostics; amplification, target, each nucleic acid sequence 

83900 Molecular diagnostics; amplification, target, multiplex, first two nucleic acid 

sequences 

83901 Molecular diagnostics; amplification, target multiplex, each additional nucleic 

acid sequence beyond the first two 

83902 Molecular diagnostics; reverse transcription 

83904 Molecular diagnostics; mutation identification by sequencing, single segment, 

each segment 

83907 Molecular diagnostics; lysis of cells prior to nucleic acid extraction 

83909 Molecular diagnostics; separation and identification by high resolution 

technique 

83912 Molecular diagnostics; interpretation and report 

83914 Mutation identification by enzymatic ligation or primer extension, single 

segment, each segment 

88271 Molecular cytogenetics; each DNA probe 

Source: American Medical Association, Current Procedural Terminology 2009 Standard Edition, pp. 276–292. 

Genetic Tests by Name Included in Review

AlloMap 

OncoTypeDX
 

PathFinderTG 

Pathwork Tissue of Origin
 

VeriStrat
 

ChemoFx 

Oncotech EDR 

MSH2 Gene Analysis 

MLH1 Gene Analysis
 

KRAS Gene Analysis 

HFE Gene Analysis 

F2 Gene Analysis
 

CFTR Gene Analysis
 

BRCA1 Gene Analysis 

BRCA2 Gene Analysis 

BCR/ABL1 Translocation Analysis 

OEI-07-11-00011 Coverage and Payment for Genetic Laboratory Tests 
 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Page 12 – Marilyn Tavenner 

APPENDIX B 

Table B-1: Iowa Medicaid Program Quantities of Stacked Codes Allowed in Reimbursement for 

Selected Genetic Tests 

Current 

Procedural 

Terminology 

Code 

Genetic Test 

Pathwork 

Tissue of 

Origin 

VeriStrat ChemoFX 

KRAS 

Gene 

Analysis 

F2 Gene 

Analysis 

BCR/ABL1 

Translocation 

Analysis 

83890 1 1 

83891 1 1 1 

83892 1 3 

83893 1 

83894 1 1 1 

83896 1 

83897 1 

83898 1 1 2 9 

83900 1 

83901 1 

83902 1 1 

83903 1 

83904 1 2 

83905 1 

83906 1 

83907 1 1 

83908 1 

83909 1 1 2 

83912 1 1 1 1 

83913 1 

83914 4 

84999 1 

87230 1 

88104 1 

88230 1 

88233 1 

88235 1 

88237 1 

88239 1 

88305 1 

88313 1 

88358 1 

88381 1 

88384 1 

88385 1 

88386 1 

89050 1 

Source: Office of Inspector General analysis of Iowa Medicaid program survey response, 2011. 

OEI-07-11-00011 Coverage and Payment for Genetic Laboratory Tests 
 

 

 

 

 

Page 13 – Marilyn Tavenner 

APPENDIX C 

Table C-1: Minnesota Medicaid Program Stacked Codes Allowed in 

Reimbursement for Selected Genetic Tests 

Current 

Procedural 

Terminology 

Code 

Genetic Test 

CFTR Gene 

Analysis 

HFE Gene 

Analysis 

MLH1 Gene 

Analysis 

MSH2 Gene 

Analysis 

83890 X X 

83891 X X X 

83892 X X X 

83893 X 

83894 X 

83896 X 

83897 X 

83898 X X X X 

83900 X 

83901 X 

83902 X 

83903 X 

83904 X X X 

83905 X 

83906 X 

83909 X X 

83912 X X X 

Source: Office of Inspector General analysis of Minnesota Medicaid program survey response, 2011. 

OEI-07-11-00011 Coverage and Payment for Genetic Laboratory Tests 
 

 

 

Page 14 – Marilyn Tavenner 

APPENDIX D 

Table D-1: Medicare Clinical Laboratory Fee Schedule, State Medicaid Program, and 

Federal Employee Health Benefit* Payment Rates for Selected Genetic Test Codes 

Current 

Procedural 

Terminology 

Code 

Insurer 

State 

AK AL AR AZ CA 

83890 

Medicare 

Medicaid 

FEHB 1 

FEHB 2 

FEHB 3 

$5.64 

$5.74 

N/A 

N/A 

$5.00 

$5.55 

$5.55 

$5.94 

N/A 

$5.36 

$5.64 

$5.72 

N/A 

N/A 

$6.72 

$5.64 

$5.45 

N/A 

$107.50 

$3.35 

$5.64 

$4.39 

N/A 

$25.20 

$4.86 

Medicare $5.64 $5.55 $5.64 $5.64 $5.64 

Medicaid $5.74 $4.00 $5.72 $5.45 $4.39 

83891 FEHB 1 N/A $3.98 $6.45 $5.94 $5.94 

FEHB 2 $4.45 $6.19 $8.40 $5.88 $5.88 

FEHB 3 $31.00 $4.95 $4.89 $4.86 $4.86 

Medicare $5.64 $5.55 $5.64 $5.64 $5.64 

Medicaid $5.74 $5.55 $5.72 $5.45 $4.39 

83892 FEHB 1 N/A N/A $31.61 N/A $5.94 

FEHB 2 $5.60 $15.10 $9.20 $6.19 $5.88 

FEHB 3 $79.11 $9.90 $7.46 $6.68 $9.90 

Medicare $5.64 $5.55 $5.64 $5.64 $5.64 

Medicaid $5.74 $5.00 $5.72 $5.45 $4.39 

83894 FEHB 1 N/A N/A $5.46 N/A $5.94 

FEHB 2 N/A $24.00 $19.00 $45.38 $11.31 

FEHB 3 $11.28 $12.44 $5.04 $5.09 $9.86 

Medicare $5.64 $5.55 $5.64 $5.64 $5.64 

Medicaid $5.74 $5.55 $5.72 $5.45 $4.39 

83896 FEHB 1 N/A $5.49 $43.07 $5.46 $5.40 

FEHB 2 $5.60 $6.19 $28.00 $5.88 $5.88 

FEHB 3 $35.56 $9.90 $7.46 $13.15 $30.00 

83897 

Medicare 

Medicaid 

FEHB 1 

FEHB 2 

FEHB 3 

$5.64 

$5.74 

N/A 

N/A 

N/A 

$5.55 

$4.00 

N/A 

N/A 

N/A 

$5.64 

$5.72 

N/A 

$55.00 

N/A 

$5.64 

$5.45 

N/A 

N/A 

N/A 

$5.64 

$4.39 

N/A 

N/A 

$6.26 

Medicare $23.58 $9.52 $23.58 $23.58 $23.58 

Medicaid $24.01 $9.52 $23.94 $22.81 $18.35 

83898 FEHB 1 N/A $24.85 N/A N/A $23.53 

FEHB 2 $14.00 $36.00 $55.00 $35.01 $35.01 

FEHB 3 $30.00 $19.38 $20.69 $22.45 $35.16 

Medicare $47.18 $19.03 $47.18 $47.18 $47.18 

Medicaid N/A $13.00 $48.40 $45.62 $37.10 

83900 FEHB 1 N/A $79.65 $48.94 $49.69 $30.99 

FEHB 2 N/A $26.18 $46.84 $38.00 $40.36 

FEHB 3 $116.68 $16.94 $40.90 $23.68 $40.68 

continued on next page 

Note: N/A indicates that no price was reported for the test. 

*FEHB. 

OEI-07-11-00011 Coverage and Payment for Genetic Laboratory Tests 
 

 

Page 15 – Marilyn Tavenner 

Table D-1: Medicare Clinical Laboratory Fee Schedule, State Medicaid Program, and 

Federal Employee Health Benefit Payment Rates for Selected Genetic Test Codes 

(Continued) 

Current 

Procedural 

Terminology 

Code 

Insurer 

State 

AK AL AR AZ CA 

Medicare $23.58 $9.52 $23.58 $23.58 $23.58 

Medicaid $24.01 $6.00 $23.94 $22.81 $18.35 

83901 FEHB 1 N/A $16.68 $21.08 $6.39 $18.55 

FEHB 2 N/A $7.32 $42.67 $15.93 $12.27 

FEHB 3 $156.26 $136.64 $204.33 $20.80 $159.97 

83902 

Medicare 

Medicaid 

FEHB 1 

FEHB 2 

FEHB 3 

$12.09 

$12.31 

N/A 

N/A 

$31.00 

$5.55 

$4.00 

N/A 

N/A 

$9.90 

$19.97 

$20.26 

$5.47 

N/A 

$8.79 

$19.97 

$19.31 

$5.47 

N/A 

$19.00 

$19.97 

$15.53 

$17.15 

N/A 

$9.90 

Medicare $23.58 $9.52 $23.58 $23.58 $23.58 

Medicaid $24.01 $7.00 $23.94 $22.81 $18.35 

83904 FEHB 1 N/A N/A $23.54 N/A $23.54 

FEHB 2 $37.86 N/A N/A $35.01 $35.01 

FEHB 3 $47.16 $83.38 $56.73 $89.79 $141.00 

83907 

Medicare 

Medicaid 

FEHB 1 

FEHB 2 

FEHB 3 

$18.80 

$19.13 

N/A 

N/A 

$16.92 

$18.80 

$13.00 

$58.80 

N/A 

$16.21 

$18.80 

$19.28 

$58.80 

N/A 

$24.87 

$18.80 

$18.17 

N/A 

N/A 

$17.88 

$18.80 

$14.78 

N/A 

N/A 

$16.21 

Medicare $23.58 $9.52 $23.58 $23.58 $23.58 

Medicaid $24.01 $7.00 $24.20 $22.81 $18.55 

83909 FEHB 1 N/A $6.13 $20.27 $14.03 $15.49 

FEHB 2 $13.00 $13.49 $23.42 $6.39 $13.49 

FEHB 3 $49.75 $9.69 $20.56 $14.59 $20.34 

Medicare $5.64 $5.55 $5.64 $5.64 $5.64 

Medicaid $5.74 $5.55 $5.72 $5.45 $4.39 

83912 FEHB 1 N/A $4.43 $6.89 $5.46 $5.94 

FEHB 2 $4.23 $37.60 $19.20 $25.80 $5.88 

FEHB 3 $11.28 $4.95 $8.40 $5.66 $4.95 

Medicare $23.58 $9.52 $23.58 $23.58 $23.58 

Medicaid $24.01 $7.00 $24.20 $22.81 $18.55 

83914 FEHB 1 N/A $39.97 $73.80 $3.20 $15.49 

FEHB 2 N/A N/A $21.99 $13.11 $15.51 

FEHB 3 $127.32 $103.78 $271.04 $50.58 $165.78 

88271 

Medicare 

Medicaid 

FEHB 1 

FEHB 2 

FEHB 3 

$30.14 

$30.68 

N/A 

N/A 

$120.56 

$23.42 

$21.00 

N/A 

N/A 

$100.00 

$30.14 

$30.59 

$30.66 

N/A 

$82.92 

$30.14 

$29.15 

N/A 

N/A 

$92.32 

$30.14 

$23.44 

N/A 

N/A 

$93.56 

continued on next page 

OEI-07-11-00011 Coverage and Payment for Genetic Laboratory Tests 
 

 

Page 16 – Marilyn Tavenner 

Table D-1: Medicare Clinical Laboratory Fee Schedule, State Medicaid Program, and 

Federal Employee Health Benefit Payment Rates for Selected Genetic Test Codes 

(Continued) 

Current 

Procedural 

Terminology 

Code 

Insurer 

State 

CO CT DC DE FL 

Medicare $5.64 $5.64 $5.64 $5.64 $3.59 

Medicaid $4.97 $5.32 $3.00 $5.53 $2.00 

83890 FEHB 1 N/A N/A N/A N/A $8.97 

FEHB 2 $5.36 N/A $4.76 N/A $20.76 

FEHB 3 $2.54 $5.54 $5.00 $4.78 $4.00 

Medicare $5.64 $5.64 $5.64 $5.64 $3.59 

Medicaid $4.97 $5.32 $88.00 $5.53 $2.00 

83891 FEHB 1 $5.78 $5.78 $5.94 N/A $5.78 

FEHB 2 $4.51 $5.06 $5.88 N/A $5.88 

FEHB 3 $4.95 $3.44 $5.00 $7.62 $4.95 

Medicare $5.64 $5.64 $5.64 $5.64 $3.59 

Medicaid $4.97 $5.32 $3.00 $5.53 $2.00 

83892 FEHB 1 $5.60 $5.25 $5.94 N/A $5.25 

FEHB 2 $5.20 $5.88 $6.19 $2.35 $6.04 

FEHB 3 $9.90 $6.88 $9.35 $9.28 $9.90 

Medicare $5.64 $5.64 $5.64 $5.64 $3.59 

Medicaid $4.97 $5.32 $3.00 $5.53 $2.00 

83894 FEHB 1 $5.94 N/A $5.94 N/A $5.94 

FEHB 2 $5.36 N/A $4.76 $2.35 $24.00 

FEHB 3 $7.63 $7.25 $5.00 $10.00 $8.31 

Medicare $5.64 $5.64 $5.64 $5.64 $3.59 

Medicaid $4.97 $5.32 $3.00 $5.53 $2.49 

83896 FEHB 1 $5.25 $5.25 $5.70 N/A $5.25 

FEHB 2 $4.09 $5.88 $5.32 N/A $5.88 

FEHB 3 $9.90 $13.76 $15.00 $11.14 $9.90 

83897 

Medicare 

Medicaid 

FEHB 1 

FEHB 2 

FEHB 3 

$5.64 

$4.97 

N/A 

N/A 

$5.60 

$5.64 

$5.32 

N/A 

N/A 

N/A 

$5.64 

$10.00 

N/A 

N/A 

N/A 

$5.64 

$5.53 

N/A 

N/A 

N/A 

$3.59 

$2.00 

N/A 

N/A 

$8.31 

Medicare $23.58 $23.58 $23.58 $23.58 $23.58 

Medicaid $20.83 $22.25 $11.00 $23.11 $2.00 

83898 FEHB 1 $23.53 $22.65 $24.85 N/A $24.85 

FEHB 2 $15.33 $24.02 $19.91 N/A $35.01 

FEHB 3 $20.69 $42.20 $10.00 $27.28 $35.00 

Medicare $47.18 $47.18 $47.18 $47.18 $47.18 

Medicaid $44.31 $44.03 $24.36 $46.24 $32.79 

83900 FEHB 1 $34.42 $104.41 $30.99 N/A $60.18 

FEHB 2 $25.16 N/A $40.36 N/A $23.98 

FEHB 3 $20.86 $28.81 $5.18 $39.99 $27.17 

continued on next page 

OEI-07-11-00011 Coverage and Payment for Genetic Laboratory Tests 
 

 

Page 17 – Marilyn Tavenner 

Table D-1: Medicare Clinical Laboratory Fee Schedule, State Medicaid Program, and 

Federal Employee Health Benefit Payment Rates for Selected Genetic Test Codes 

(Continued) 

Current 

Procedural 

Terminology 

Code 

Insurer 

State 

CO CT DC DE FL 

Medicare $23.58 $23.58 $23.58 $23.58 $23.58 

Medicaid $20.83 $22.25 $10.00 $23.11 $16.00 

83901 FEHB 1 $16.68 N/A $18.56 N/A $22.32 

FEHB 2 $15.57 N/A $19.91 N/A $11.99 

FEHB 3 $144.84 $160.01 $70.00 $159.38 $160.11 

83902 

Medicare 

Medicaid 

FEHB 1 

FEHB 2 

FEHB 3 

$19.97 

$17.63 

$21.04 

N/A 

$9.90 

$19.97 

$18.84 

N/A 

N/A 

$27.70 

$19.97 

$9.00 

N/A 

N/A 

$19.00 

$19.97 

$19.57 

N/A 

N/A 

$31.00 

$15.28 

$10.50 

$16.86 

N/A 

$19.68 

Medicare $23.58 $23.58 $23.58 $23.58 $23.58 

Medicaid $20.83 $22.25 $32.00 $23.11 $16.00 

83904 FEHB 1 N/A N/A N/A N/A $20.98 

FEHB 2 $35.01 $13.02 N/A N/A $35.01 

FEHB 3 $93.68 $59.15 $54.42 $122.07 $89.79 

83907 

Medicare 

Medicaid 

FEHB 1 

FEHB 2 

FEHB 3 

$18.80 

$12.54 

$58.80 

N/A 

$13.00 

$18.80 

$17.54 

N/A 

N/A 

$33.63 

$17.28 

$8.92 

N/A 

N/A 

$25.20 

$18.80 

$18.42 

N/A 

N/A 

$25.05 

$18.80 

$13.06 

$15.87 

N/A 

$13.00 

Medicare $23.58 $23.58 $23.58 $23.58 $23.58 

Medicaid $15.74 $22.01 $12.18 $23.11 $16.39 

83909 FEHB 1 $18.75 $52.19 $24.85 N/A $30.26 

FEHB 2 $22.40 $13.26 $14.83 N/A $11.96 

FEHB 3 $10.35 $14.41 $2.59 $19.99 $13.58 

Medicare $5.64 $5.64 $5.64 $5.64 $3.59 

Medicaid $5.25 $2.66 $3.00 $5.53 $10.18 

83912 FEHB 1 $5.25 $5.25 $5.94 N/A $5.94 

FEHB 2 $4.09 $4.85 $5.88 $2.35 $5.88 

FEHB 3 $4.95 $5.54 $5.00 $5.57 $4.95 

Medicare $23.58 $23.58 $23.58 $23.58 $23.58 

Medicaid $15.74 $22.01 $12.18 $23.11 $16.39 

83914 FEHB 1 $33.02 N/A $15.49 N/A $18.20 

FEHB 2 $11.86 $19.17 $19.17 N/A $11.99 

FEHB 3 $287.90 $392.32 $82.88 $383.12 $394.19 

Medicare $30.14 $30.14 $30.14 $30.14 $20.37 

Medicaid $26.61 $28.43 $84.00 $29.54 $14.00 

88271 FEHB 1 $48.00 N/A N/A N/A $31.75 

FEHB 2 N/A N/A $68.93 N/A $76.00 

FEHB 3 $179.58 $232.56 $91.00 $23.39 $78.86 

continued on next page 

OEI-07-11-00011 Coverage and Payment for Genetic Laboratory Tests 
 

 

Page 18 – Marilyn Tavenner 

Table D-1: Medicare Clinical Laboratory Fee Schedule, State Medicaid Program, and 

Federal Employee Health Benefit Payment Rates for Selected Genetic Test Codes 

(Continued) 

Current 

Procedural 

Terminology 

Code 

Insurer 

State 

GA HI IA ID IL 

Medicare $5.55 $5.64 $5.64 $5.64 $5.64 

Medicaid $4.96 $5.54 $5.36 $5.60 $5.25 

83890 FEHB 1 $7.35 N/A $56.32 N/A $7.64 

FEHB 2 $7.30 N/A N/A N/A N/A 

FEHB 3 $4.34 N/A $7.00 $6.66 $7.00 

Medicare $5.55 $5.64 $5.64 $5.64 $5.64 

Medicaid $4.96 $5.54 $5.36 $5.60 $5.25 

83891 FEHB 1 $5.94 N/A N/A $5.78 $2.92 

FEHB 2 $5.88 N/A N/A N/A $7.81 

FEHB 3 $4.95 $7.42 $6.52 $4.45 $4.95 

Medicare $5.55 $5.64 $5.64 $5.64 $5.64 

Medicaid $4.96 $5.54 $5.36 $5.60 $5.05 

83892 FEHB 1 $5.46 N/A N/A N/A N/A 

FEHB 2 $5.94 N/A N/A N/A $7.00 

FEHB 3 $9.90 $15.20 $21.00 N/A $9.90 

Medicare $5.55 $5.64 $5.64 $5.64 $5.64 

Medicaid $4.96 $5.54 $5.36 $5.60 $5.05 

83894 FEHB 1 $5.26 N/A N/A N/A N/A 

FEHB 2 $14.94 N/A N/A N/A $14.94 

FEHB 3 $5.46 $19.00 $12.00 $3.94 $5.85 

Medicare $5.55 $5.64 $5.64 $5.64 $5.64 

Medicaid $4.96 $5.54 $5.36 $5.60 $5.25 

83896 FEHB 1 $5.46 N/A $45.07 N/A $9.26 

FEHB 2 $5.88 N/A N/A N/A $10.64 

FEHB 3 $9.90 $7.23 $14.00 $30.00 $9.90 

83897 

Medicare 

Medicaid 

FEHB 1 

FEHB 2 

FEHB 3 

$5.55 

$4.96 

N/A 

N/A 

$4.41 

$5.64 

$5.54 

N/A 

N/A 

$7.23 

$5.64 

$5.36 

N/A 

N/A 

N/A 

$5.64 

$5.60 

N/A 

N/A 

N/A 

$5.64 

$5.25 

N/A 

N/A 

$7.42 

Medicare $5.40 $23.58 $23.58 $5.80 $23.58 

Medicaid $4.83 $23.17 $22.40 $5.75 $21.90 

83898 FEHB 1 $24.19 N/A $218.52 $22.66 $36.54 

FEHB 2 $35.01 N/A N/A N/A $36.00 

FEHB 3 $10.00 $168.02 $34.00 $32.94 $20.34 

Medicare $10.82 $47.18 $47.18 $11.58 $47.18 

Medicaid $9.67 $28.10 $44.82 $11.50 $28.10 

83900 FEHB 1 $65.42 N/A N/A N/A $44.85 

FEHB 2 $37.47 N/A N/A N/A $32.47 

FEHB 3 $10.56 $60.52 $78.27 $47.78 $34.00 

continued on next page 

OEI-07-11-00011 Coverage and Payment for Genetic Laboratory Tests 
 

Page 19 – Marilyn Tavenner 

Table D-1: Medicare Clinical Laboratory Fee Schedule, State Medicaid Program, and 

Federal Employee Health Benefit Payment Rates for Selected Genetic Test Codes 

(Continued) 

Current 

Procedural 

Terminology 

Code 

Insurer 

State 

GA HI IA ID IL 

Medicare $5.40 $23.58 $23.58 $5.80 $23.58 

Medicaid $4.83 $23.17 $22.40 $5.75 $21.90 

83901 FEHB 1 $24.85 N/A N/A N/A $12.26 

FEHB 2 $15.00 N/A N/A N/A $22.88 

FEHB 3 $73.92 $665.72 $5.22 $93.91 $221.00 

Medicare $17.82 $19.97 $19.97 $5.80 $19.97 

Medicaid $15.92 $19.61 $18.97 $5.75 $18.50 

83902 FEHB 1 $5.26 N/A N/A N/A $40.80 

FEHB 2 $36.60 N/A N/A N/A N/A 

FEHB 3 $19.00 N/A $23.00 $14.01 $23.00 

Medicare $5.40 $23.58 $23.58 $5.80 $23.58 

Medicaid $4.83 $23.17 $22.40 $5.75 $21.90 

83904 FEHB 1 $35.98 N/A N/A N/A N/A 

FEHB 2 $35.01 N/A N/A N/A N/A 

FEHB 3 $32.07 $272.34 $90.00 $0.00 $371.01 

83907 

Medicare 

Medicaid 

FEHB 1 

FEHB 2 

FEHB 3 

$18.80 

$16.79 

$33.02 

N/A 

$17.88 

$18.80 

$13.06 

N/A 

N/A 

N/A 

$18.80 

$17.86 

N/A 

N/A 

$22.00 

$18.80 

$18.66 

N/A 

N/A 

$13.12 

$18.80 

$11.19 

N/A 

N/A 

$17.88 

Medicare $5.40 $23.58 $23.58 $5.80 $23.58 

Medicaid $4.83 $16.39 $22.40 $5.75 $14.05 

83909 FEHB 1 $30.27 N/A N/A $30.00 $102.33 

FEHB 2 $13.49 N/A N/A N/A $12.26 

FEHB 3 $12.29 $40.75 $48.00 $345.60 $17.25 

Medicare $5.55 $5.64 $5.64 $5.64 $5.64 

Medicaid $4.96 $5.60 N/A $5.60 $5.25 

83912 FEHB 1 $5.46 N/A $54.95 $5.25 $9.26 

FEHB 2 $5.88 N/A N/A N/A $10.69 

FEHB 3 $4.95 $8.40 $7.00 $5.36 $22.33 

Medicare $5.40 $23.58 $23.58 $5.80 $23.58 

Medicaid $4.83 $16.39 $22.40 $5.75 $14.05 

83914 FEHB 1 $24.85 N/A N/A $38.82 $6.14 

FEHB 2 $18.74 N/A N/A N/A $12.69 

FEHB 3 $215.51 $394.19 $82.88 $229.04 $340.00 

Medicare $30.14 $30.14 $30.14 $20.37 $20.37 

Medicaid $26.94 $29.60 $28.63 $20.22 $18.90 

88271 FEHB 1 $30.00 N/A N/A N/A N/A 

FEHB 2 $88.95 N/A N/A N/A N/A 

FEHB 3 $86.04 N/A $442.00 $51.98 $109.50 

continued on next page 

OEI-07-11-00011 Coverage and Payment for Genetic Laboratory Tests 
 

 

 

Page 20 – Marilyn Tavenner 

Table D-1: Medicare Clinical Laboratory Fee Schedule, State Medicaid Program, and 

Federal Employee Health Benefit Payment Rates for Selected Genetic Test Codes 

(Continued) 

Current 

Procedural 

Terminology 

Code 

Insurer 

State 

IN KS* KY LA MA 

83890 

Medicare 

Medicaid 

FEHB 1 

FEHB 2 

FEHB 3 

$5.64 

$5.54 

$8.77 

N/A 

$7.18 

$3.29/$5.64* 

$5.54 

N/A 

N/A 

$5.55 

$5.55 

$5.55 

N/A 

$5.65 

$4.55 

$5.64 

$4.15 

N/A 

$10.83 

$7.24 

$5.64 

$4.18 

$9.36 

N/A 

$6.26 

Medicare $5.64 $3.29/$5.64* $5.55 $5.64 $5.64 

Medicaid $5.54 $5.54 $5.55 $4.56 $4.18 

83891 FEHB 1 $4.26 $6.01 $9.64 $5.04 $9.36 

FEHB 2 $5.06 N/A $5.88 $5.88 $5.88 

FEHB 3 $3.51 $4.95 $2.92 $4.95 $6.26 

Medicare $5.64 $3.29/$5.64* $5.55 $5.64 $5.64 

Medicaid $5.54 $5.54 $5.55 $4.15 $4.18 

83892 FEHB 1 N/A $5.94 $5.25 $16.52 N/A 

FEHB 2 $14.94 N/A $14.94 $7.05 $5.88 

FEHB 3 $7.90 $9.90 $10.66 $9.90 $6.26 

Medicare $5.64 $3.29/$5.64* $5.55 $5.64 $5.64 

Medicaid $5.54 $5.54 $5.55 $4.15 $4.18 

83894 FEHB 1 N/A $5.94 N/A $28.00 N/A 

FEHB 2 $24.00 N/A $24.00 $24.00 N/A 

FEHB 3 $7.63 $5.00 $16.53 $8.88 $16.20 

Medicare $5.64 $3.29/$5.64* $5.55 $5.64 $5.64 

Medicaid $5.54 $5.54 $5.55 $4.15 $4.18 

83896 FEHB 1 $5.60 $5.46 $5.25 $16.52 $9.36 

FEHB 2 $5.88 N/A $5.77 $5.88 $5.88 

FEHB 3 $23.69 $9.90 $19.52 $9.90 $12.52 

83897 

Medicare 

Medicaid 

FEHB 1 

FEHB 2 

FEHB 3 

$5.64 

$5.54 

N/A 

N/A 

N/A 

$3.29/ $5.64* 

$5.54 

N/A 

N/A 

N/A 

$5.55 

$5.55 

N/A 

N/A 

N/A 

$5.64 

$4.56 

$23.80 

N/A 

$15.52 

$5.64 

$4.18 

N/A 

N/A 

$111.32 

Medicare $23.58 $23.58 $23.58 $23.58 $6.14 

Medicaid $23.17 $21.60 $23.58 $17.32 $4.55 

83898 FEHB 1 $23.42 $23.75 N/A $21.08 $16.42 

FEHB 2 $35.01 N/A $30.01 $35.51 N/A 

FEHB 3 $26.94 $43.89 $20.11 $20.34 $29.15 

Medicare $47.18 $47.18 $47.18 $47.18 $12.29 

Medicaid $46.84 $39.81 $47.18 $19.60 $9.11 

83900 FEHB 1 $63.24 $92.46 N/A $106.02 N/A 

FEHB 2 $24.57 N/A $24.57 $40.36 N/A 

FEHB 3 $29.37 $41.12 $31.77 $36.02 $46.50 

continued on next page 

* Four States (CA, KS, MO, and NY) are divided into multiple Medicare carrier jurisdictions. Each jurisdiction may have a different price for 

some Current Procedural Terminology codes. In jurisdictions where prices differ, differences are signified using “/” between each 

jurisdiction’s price. 

OEI-07-11-00011 Coverage and Payment for Genetic Laboratory Tests 
 

 

 

Page 21 – Marilyn Tavenner 

Table D-1: Medicare Clinical Laboratory Fee Schedule, State Medicaid Program, and 

Federal Employee Health Benefit Payment Rates for Selected Genetic Test Codes 

(Continued) 

Current 

Procedural 

Terminology 

Code 

Insurer 

State 

IN KS* KY LA MA 

Medicare $23.58 $23.58 $23.58 $23.58 $6.14 

Medicaid $23.17 $5.54 $23.58 $19.04 $4.55 

83901 FEHB 1 $30.15 N/A N/A $12.26 N/A 

FEHB 2 $12.26 N/A $12.26 $37.13 N/A 

FEHB 3 $87.08 $960.00 $157.82 $159.38 $116.05 

83902 

Medicare 

Medicaid 

FEHB 1 

FEHB 2 

FEHB 3 

$19.97 

$19.61 

N/A 

N/A 

$12.43 

$19.97 

N/A 

$5.47 

N/A 

$17.67 

$19.97 

$19.97 

$41.40 

N/A 

$5.00 

$19.97 

$16.11 

N/A 

N/A 

$40.66 

$5.80 

$4.29 

$5.26 

N/A 

$13.09 

Medicare $23.58 $23.58 $23.58 $23.58 $6.14 

Medicaid $23.17 $21.60 $23.58 $19.04 $4.55 

83904 FEHB 1 $16.25 N/A N/A N/A $22.66 

FEHB 2 $13.02 N/A N/A N/A N/A 

FEHB 3 $44.04 $347.74 $43.22 $1,087.05 $71.88 

83907 

Medicare 

Medicaid 

FEHB 1 

FEHB 2 

FEHB 3 

$18.80 

$18.66 

$30.00 

N/A 

$20.64 

$18.80 

$15.86 

N/A 

N/A 

$16.21 

$12.65 

$12.65 

N/A 

N/A 

$13.00 

$18.80 

$15.34 

N/A 

N/A 

$20.56 

$18.80 

$13.93 

N/A 

N/A 

$13.00 

Medicare $23.58 $23.58 $23.58 $23.58 $6.14 

Medicaid $23.42 $19.91 $23.58 $19.25 $4.55 

83909 FEHB 1 $24.21 $30.27 N/A $6.13 N/A 

FEHB 2 $13.02 N/A $12.26 $12.26 N/A 

FEHB 3 $21.62 $21.91 $11.65 $24.01 $23.25 

Medicare $5.64 $3.29/$5.64* $5.55 $5.64 $5.64 

Medicaid $5.54 $5.54 $5.55 $4.15 $4.18 

83912 FEHB 1 $5.60 $5.46 $5.25 $17.96 $7.31 

FEHB 2 $4.85 N/A $5.65 $8.17 $31.86 

FEHB 3 $4.15 $4.95 $14.72 $5.74 $6.26 

Medicare $23.58 $23.58 $23.58 $23.58 $6.14 

Medicaid $23.42 $19.91 $23.58 $19.25 $8.75 

83914 FEHB 1 $14.78 $34.30 N/A $39.97 N/A 

FEHB 2 $19.17 N/A $12.28 $12.28 N/A 

FEHB 3 $94.32 $232.50 $327.04 $51.03 $232.50 

88271 

Medicare 

Medicaid 

FEHB 1 

FEHB 2 

FEHB 3 

$20.37 

$20.00 

$69.27 

N/A 

$76.08 

$30.14 

$25.44 

N/A 

N/A 

$168.86 

$20.37 

$20.37 

N/A 

N/A 

$71.75 

$30.14 

$24.32 

$31.75 

N/A 

$40.04 

$30.14 

$22.35 

N/A 

N/A 

$66.88 

continued on next page 

* Four States (CA, KS, MO, and NY) are divided into multiple Medicare carrier jurisdictions. Each jurisdiction may have a different price for 

some Current Procedural Terminology codes. In jurisdictions where prices differ, differences are signified using “/” between each 

jurisdiction’s price. 

OEI-07-11-00011 Coverage and Payment for Genetic Laboratory Tests 
 

 

 

Page 22 – Marilyn Tavenner 

Table D-1: Medicare Clinical Laboratory Fee Schedule, State Medicaid Program, and 

Federal Employee Health Benefit Payment Rates for Selected Genetic Test Codes 

(Continued) 

Current 

Procedural 

Terminology 

Code 

Insurer 

State 

MD ME MI MN MO* 

Medicare $5.64 $5.64 $5.64 $5.64 $3.29/$5.64* 

Medicaid $4.27 $5.67 $4.41 $5.64 $3.07 

83890 FEHB 1 $5.94 N/A N/A N/A N/A 

FEHB 2 $4.76 N/A N/A N/A $51.82 

FEHB 3 $5.00 $6.18 $5.89 $8.09 $4.71 

Medicare $5.64 $5.64 $5.64 $5.64 $3.29/$5.64* 

Medicaid $4.27 $5.54 $4.41 $5.64 $3.07 

83891 FEHB 1 $5.79 $5.04 N/A $81.18 $5.78 

FEHB 2 $4.76 $4.56 $4.23 N/A $5.88 

FEHB 3 $4.95 $5.54 $6.16 $8.09 $4.95 

Medicare $5.64 $5.64 $5.64 $5.64 $3.29/$5.64* 

Medicaid $4.27 $5.67 $4.42 $5.64 $3.07 

83892 FEHB 1 $5.25 N/A N/A $13.60 $5.25 

FEHB 2 $5.88 N/A $5.88 N/A $5.88 

FEHB 3 $9.90 $6.26 $9.72 $8.09 $9.90 

Medicare $5.64 $5.64 $5.64 $5.64 $3.29/$5.64* 

Medicaid $4.27 $5.67 $4.41 $5.64 $3.07 

83894 FEHB 1 $5.36 N/A N/A $16.15 N/A 

FEHB 2 $4.76 N/A N/A N/A $8.26 

FEHB 3 $5.00 $15.45 $5.60 $8.09 $5.26 

Medicare $5.64 $5.64 $5.64 $5.64 $3.29/$5.64* 

Medicaid $4.27 $5.67 $4.41 $5.64 $3.07 

83896 FEHB 1 $5.46 $5.04 N/A N/A $5.25 

FEHB 2 $4.76 N/A N/A N/A $9.02 

FEHB 3 $9.90 $20.28 $43.91 $8.87 $11.02 

83897 

Medicare 

Medicaid 

FEHB 1 

FEHB 2 

FEHB 3 

$5.64 

$4.27 

N/A 

N/A 

N/A 

$5.64 

$5.54 

N/A 

N/A 

$9.02 

$5.64 

$4.41 

N/A 

N/A 

N/A 

$5.64 

$5.64 

N/A 

N/A 

$41.61 

$3.29/$5.64* 

$3.07 

N/A 

N/A 

N/A 

Medicare $14.32 $6.14 $23.58 $23.58 $23.58 

Medicaid $10.84 $6.03 $15.90 $23.58 $18.07 

83898 FEHB 1 $22.65 N/A N/A N/A N/A 

FEHB 2 $19.91 N/A $35.97 N/A $16.22 

FEHB 3 $15.00 $27.28 $31.63 $33.85 $46.00 

Medicare $28.65 $12.29 $47.18 $47.18 $47.18 

Medicaid $21.66 $12.20 $36.84 $47.18 $44.06 

83900 FEHB 1 $29.89 $147.00 N/A $104.55 $104.41 

FEHB 2 $40.36 $24.57 $32.47 N/A $40.36 

FEHB 3 $12.00 $13.23 $51.52 $42.60 $28.33 

continued on next page 

* Four States (CA, KS, MO, and NY) are divided into multiple Medicare carrier jurisdictions. Each jurisdiction may have a different price for 

some Current Procedural Terminology codes. In jurisdictions where prices differ, differences are signified using “/” between each 

jurisdiction’s price. 

OEI-07-11-00011 Coverage and Payment for Genetic Laboratory Tests 
 

 

Page 23 – Marilyn Tavenner 

Table D-1: Medicare Clinical Laboratory Fee Schedule, State Medicaid Program, and 

Federal Employee Health Benefit Payment Rates for Selected Genetic Test Codes 

(Continued) 

Current 

Procedural 

Terminology 

Code 

Insurer 

State 

MD ME MI MN MO* 

Medicare $14.32 $6.14 $23.58 $23.58 $23.58 

Medicaid $10.84 $6.03 $18.42 $23.58 $22.02 

83901 FEHB 1 $24.76 $21.08 N/A N/A N/A 

FEHB 2 $22.88 $12.31 $12.26 N/A $12.28 

FEHB 3 $95.00 $88.40 $467.82 $0.90 $114.73 

83902 

Medicare 

Medicaid 

FEHB 1 

FEHB 2 

FEHB 3 

$14.32 

$10.39 

$5.26 

N/A 

$13.10 

$5.80 

$5.69 

N/A 

N/A 

$46.30 

$19.97 

$15.58 

N/A 

N/A 

$31.00 

$16.56 

$16.56 

N/A 

N/A 

$37.08 

$19.97 

$18.65 

$5.26 

N/A 

$20.00 

Medicare $14.32 $6.14 $23.58 $23.58 $23.58 

Medicaid $10.84 $6.03 $18.42 $23.58 $22.02 

83904 FEHB 1 $22.66 N/A N/A N/A N/A 

FEHB 2 $12.18 N/A $35.97 N/A $44.38 

FEHB 3 $89.79 $186.00 $447.48 $24.61 $31.19 

83907 

Medicare 

Medicaid 

FEHB 1 

FEHB 2 

FEHB 3 

$18.80 

$14.21 

N/A 

N/A 

$16.21 

$18.80 

$18.66 

$58.80 

N/A 

$20.85 

$6.81 

$5.08 

N/A 

N/A 

$18.53 

$18.80 

$18.80 

N/A 

N/A 

$26.97 

$18.80 

$17.55 

N/A 

N/A 

$19.00 

Medicare $14.32 $6.14 $23.58 $23.58 $23.58 

Medicaid $10.84 $6.10 $18.42 $23.58 $22.02 

83909 FEHB 1 $32.17 N/A N/A N/A $52.19 

FEHB 2 $13.49 $12.26 $12.88 N/A $13.49 

FEHB 3 $14.88 $23.25 $25.76 $17.25 $20.34 

Medicare $5.64 $5.64 $5.64 $5.64 $3.29/$5.64* 

Medicaid $5.60 $5.67 $4.14 $5.64 $3.07 

83912 FEHB 1 $5.25 N/A N/A $46.75 $5.25 

FEHB 2 $5.60 $8.09 $5.06 N/A $6.94 

FEHB 3 $5.00 $5.69 $26.70 $30.98 $4.95 

Medicare $14.32 $6.14 $23.58 $23.58 $23.58 

Medicaid $10.84 $6.10 $18.42 $23.58 $22.02 

83914 FEHB 1 N/A $73.80 N/A N/A N/A 

FEHB 2 $19.17 $12.26 $12.28 N/A $12.27 

FEHB 3 $181.30 $232.50 $51.52 $0.90 $142.38 

88271 

Medicare 

Medicaid 

FEHB 1 

FEHB 2 

FEHB 3 

$30.14 

$22.80 

N/A 

$41.90 

$91.00 

$30.14 

$31.27 

$28.45 

N/A 

$241.66 

$20.37 

$16.07 

N/A 

N/A 

$93.56 

$30.14 

$30.14 

N/A 

N/A 

$26.52 

$30.14 

$28.14 

N/A 

N/A 

$126.12 

continued on next page 

* Four States (CA, KS, MO, and NY) are divided into multiple Medicare carrier jurisdictions. Each jurisdiction may have a different price for 

some Current Procedural Terminology codes. In jurisdictions where prices differ, differences are signified using “/” between each 

jurisdiction’s price. 

OEI-07-11-00011 Coverage and Payment for Genetic Laboratory Tests 
 

 

Page 24 – Marilyn Tavenner 

Table D-1: Medicare Clinical Laboratory Fee Schedule, State Medicaid Program, and 

Federal Employee Health Benefit Payment Rates for Selected Genetic Test Codes 

(Continued) 

Current 

Procedural 

Terminology 

Code 

Insurer 

State 

MS MT NC ND NE 

83890 

Medicare 

Medicaid 

FEHB 1 

FEHB 2 

FEHB 3 

$5.64 

$5.17 

N/A 

N/A 

$23.00 

$5.64 

$5.64 

N/A 

N/A 

$5.00 

$5.64 

$5.10 

N/A 

$36.00 

$3.02 

$5.64 

$5.74 

N/A 

N/A 

$7.00 

$5.64 

$5.64 

N/A 

$28.00 

$10.06 

Medicare $5.64 $5.64 $5.64 $5.64 $5.64 

Medicaid $5.17 $5.64 $5.10 $5.74 $5.64 

83891 FEHB 1 $5.94 N/A $5.94 N/A $5.04 

FEHB 2 $15.96 $11.76 $5.88 N/A $10.92 

FEHB 3 $4.95 $2.54 $4.95 $12.61 $9.76 

Medicare $5.64 $5.64 $5.64 $5.64 $5.64 

Medicaid $5.17 $5.64 $5.10 $5.74 $5.64 

83892 FEHB 1 $5.94 N/A $5.46 N/A $8.04 

FEHB 2 N/A N/A $23.50 N/A $22.50 

FEHB 3 $9.90 $18.64 $9.90 $9.13 $9.76 

Medicare $5.64 $5.64 $5.64 $5.64 $5.64 

Medicaid $5.17 $5.64 $5.10 $5.74 $5.64 

83894 FEHB 1 N/A N/A $5.94 N/A N/A 

FEHB 2 $15.96 N/A $24.00 N/A $39.00 

FEHB 3 $15.00 N/A $10.00 N/A $9.76 

Medicare $5.64 $5.64 $5.64 $5.64 $5.64 

Medicaid $5.17 $5.64 $5.10 $5.74 $5.64 

83896 FEHB 1 N/A N/A N/A N/A $6.54 

FEHB 2 N/A N/A $22.00 N/A $39.00 

FEHB 3 $9.90 $183.17 $9.90 $38.96 $10.28 

83897 

Medicare 

Medicaid 

FEHB 1 

FEHB 2 

FEHB 3 

$5.64 

$5.17 

N/A 

N/A 

N/A 

$5.64 

$5.64 

N/A 

N/A 

N/A 

$5.64 

$5.10 

N/A 

N/A 

N/A 

$5.64 

$5.74 

N/A 

N/A 

N/A 

$5.64 

$5.64 

N/A 

$10.92 

N/A 

83898 

Medicare 

Medicaid 

FEHB 1 

FEHB 2 

FEHB 3 

$23.58 

$21.61 

N/A 

$20.00 

$35.00 

$23.58 

$23.58 

N/A 

$83.00 

$20.51 

$5.80 

$5.23 

N/A 

$35.01 

$10.00 

$23.58 

$24.01 

N/A 

N/A 

$52.25 

$23.58 

$23.58 

$22.65 

N/A 

$71.50 

83900 

Medicare 

Medicaid 

FEHB 1 

FEHB 2 

FEHB 3 

$47.18 

$43.22 

$49.69 

N/A 

$26.24 

$47.18 

$47.17 

N/A 

N/A 

$20.86 

$11.58 

N/A 

$49.69 

$12.02 

$5.18 

$47.18 

$48.02 

N/A 

N/A 

$98.45 

$47.18 

$47.18 

N/A 

$55.00 

$60.82 

continued on next page 

OEI-07-11-00011 Coverage and Payment for Genetic Laboratory Tests 
 

 

Page 25 – Marilyn Tavenner 

Table D-1: Medicare Clinical Laboratory Fee Schedule, State Medicaid Program, and 

Federal Employee Health Benefit Payment Rates for Selected Genetic Test Codes 

(Continued) 

Current 

Procedural 

Terminology 

Code 

Insurer 

State 

MS MT NC ND NE 

83901 

Medicare 

Medicaid 

FEHB 1 

FEHB 2 

FEHB 3 

$23.58 

$21.61 

$24.85 

N/A 

$82.50 

$23.58 

$23.58 

N/A 

N/A 

$82.76 

$5.80 

$5.23 

$24.85 

N/A 

$52.36 

$23.58 

$24.01 

N/A 

N/A 

N/A 

$23.58 

$23.58 

N/A 

N/A 

$167.40 

83902 

Medicare 

Medicaid 

FEHB 1 

FEHB 2 

FEHB 3 

$5.80 

$5.31 

N/A 

N/A 

N/A 

$19.97 

$19.96 

N/A 

N/A 

$30.50 

$5.80 

$5.23 

N/A 

N/A 

$10.00 

$19.97 

$20.33 

N/A 

N/A 

$43.00 

$19.97 

$19.97 

$28.46 

N/A 

$7.67 

83904 

Medicare 

Medicaid 

FEHB 1 

FEHB 2 

FEHB 3 

$23.58 

$21.61 

N/A 

N/A 

$16.52 

$23.58 

$23.58 

N/A 

N/A 

N/A 

$5.80 

$5.23 

N/A 

$13.02 

$193.05 

$23.58 

$24.01 

N/A 

N/A 

$78.00 

$23.58 

$23.58 

N/A 

N/A 

$100.00 

83907 

Medicare 

Medicaid 

FEHB 1 

FEHB 2 

FEHB 3 

$9.83 

$9.01 

N/A 

N/A 

$16.21 

$18.80 

$18.79 

N/A 

N/A 

N/A 

$18.80 

$16.98 

N/A 

N/A 

$10.00 

$18.80 

N/A 

N/A 

N/A 

$20.85 

$18.80 

$18.80 

$58.80 

N/A 

$28.70 

Medicare $23.58 $23.58 $5.80 $23.58 $23.58 

Medicaid $21.61 $23.58 $5.23 $24.01 $23.58 

83909 FEHB 1 $24.85 N/A $31.07 N/A $3.73 

FEHB 2 N/A N/A $13.26 N/A N/A 

FEHB 3 $23.25 N/A $2.59 $86.00 $25.41 

Medicare $5.64 $5.64 $5.64 $5.64 $5.64 

Medicaid $5.17 $5.64 $5.10 $5.74 $5.64 

83912 FEHB 1 $5.94 N/A $5.94 N/A $5.25 

FEHB 2 $15.96 $37.00 $26.30 N/A $37.00 

FEHB 3 $4.95 $2.54 $4.95 $12.50 $9.76 

Medicare $23.58 $23.58 $5.80 $23.58 $23.58 

Medicaid $21.61 $23.58 $5.23 $24.01 $23.58 

83914 FEHB 1 $24.80 N/A N/A N/A $59.79 

FEHB 2 N/A N/A $12.59 N/A $23.00 

FEHB 3 $167.70 $268.63 $82.88 $81.50 $210.00 

88271 

Medicare 

Medicaid 

FEHB 1 

FEHB 2 

FEHB 3 

$30.14 

$27.61 

N/A 

$30.00 

N/A 

$20.37 

$20.37 

N/A 

N/A 

$182.00 

$20.37 

$18.40 

N/A 

N/A 

$136.29 

$30.14 

$30.68 

N/A 

N/A 

$81.44 

$30.14 

$30.14 

N/A 

N/A 

$520.00 

continued on next page 

OEI-07-11-00011 Coverage and Payment for Genetic Laboratory Tests 
 

 

Page 26 – Marilyn Tavenner 

Table D-1: Medicare Clinical Laboratory Fee Schedule, State Medicaid Program, and 

Federal Employee Health Benefit Payment Rates for Selected Genetic Test Codes 

(Continued) 

Current 

Procedural 

Terminology 

Code 

Insurer 

State 

NH NJ NM NV NY 

83890 

Medicare 

Medicaid 

FEHB 1 

FEHB 2 

FEHB 3 

$5.64 

$3.44 

N/A 

N/A 

$5.81 

$5.64 

$4.51 

N/A 

N/A 

$5.00 

$5.64 

$5.64 

N/A 

N/A 

$38.01 

$5.64 

$2.80 

N/A 

N/A 

$4.93 

$5.64 

$5.54 

N/A 

N/A 

$6.26 

Medicare $5.64 $5.64 $5.64 $5.64 $5.64 

Medicaid $3.32 $4.51 $5.64 $2.80 $5.54 

83891 FEHB 1 N/A $5.78 $5.78 $6.72 $10.97 

FEHB 2 N/A $5.88 $11.91 $5.88 $5.88 

FEHB 3 $6.26 $4.95 $3.94 $5.00 $4.82 

Medicare $5.64 $5.64 $5.64 $5.64 $5.64 

Medicaid $3.44 $4.51 $5.64 $2.80 $5.54 

83892 FEHB 1 N/A $5.25 N/A $5.40 $16.00 

FEHB 2 N/A $24.00 $5.04 $5.88 $10.94 

FEHB 3 $16.20 $9.90 $7.46 $7.46 $7.84 

Medicare $5.64 $5.64 $5.64 $5.64 $5.64 

Medicaid $3.44 $4.51 $5.64 $2.80 $5.54 

83894 FEHB 1 N/A $4.44 N/A N/A $16.00 

FEHB 2 N/A $6.19 $11.91 $24.00 $20.00 

FEHB 3 $6.26 $9.64 $3.94 $10.00 $6.26 

Medicare $5.64 $5.64 $5.64 $5.64 $5.64 

Medicaid $3.44 $4.51 $5.64 $2.80 $5.54 

83896 FEHB 1 N/A $5.25 N/A $5.40 $16.00 

FEHB 2 N/A $3.94 $8.90 $5.88 $5.88 

FEHB 3 $314.50 $9.90 $7.88 $8.68 $14.04 

Medicare $5.64 $5.64 $5.64 $5.64 $5.64 

Medicaid $3.32 $4.51 $5.64 $2.80 $5.54 

83897 FEHB 1 N/A N/A N/A N/A $22.00 

FEHB 2 N/A $3.00 N/A N/A $22.00 

FEHB 3 N/A $21.13 N/A $15.00 $8.86 

Medicare $6.14 $23.58 $23.58 $23.58 $23.58 

Medicaid $3.75 $18.86 $23.58 $11.72 $15.89 

83898 FEHB 1 N/A $22.65 $22.65 $22.32 N/A 

FEHB 2 N/A $35.51 $49.82 $35.01 $35.01 

FEHB 3 $223.74 $35.00 $32.94 $26.53 $41.86 

Medicare $12.29 $47.18 $47.18 $47.18 $47.18 

Medicaid $9.76 $37.74 $47.18 $23.42 $31.78 

83900 FEHB 1 N/A $37.47 $46.03 $67.23 $57.29 

FEHB 2 N/A $40.36 $40.36 $40.36 $28.46 

FEHB 3 $46.50 $32.08 $32.94 $23.42 $33.61 

continued on next page 

OEI-07-11-00011 Coverage and Payment for Genetic Laboratory Tests 
 

 

Page 27 – Marilyn Tavenner 

Table D-1: Medicare Clinical Laboratory Fee Schedule, State Medicaid Program, and 

Federal Employee Health Benefit Payment Rates for Selected Genetic Test Codes 

(Continued) 

Current 

Procedural 

Terminology 

Code 

Insurer 

State 

NH NJ NM NV NY* 

Medicare $6.14 $23.58 $23.58 $23.58 $23.58 

Medicaid $3.62 $18.86 $10.70 $11.72 $15.89 

83901 FEHB 1 N/A $9.93 N/A $33.61 $25.42 

FEHB 2 N/A $22.88 $26.22 $12.27 $12.05 

FEHB 3 $116.25 $121.75 $297.08 $99.12 $129.42 

83902 

Medicare 

Medicaid 

FEHB 1 

FEHB 2 

FEHB 3 

$5.80 

$4.55 

N/A 

N/A 

N/A 

$19.97 

$15.98 

N/A 

N/A 

$16.93 

$10.70 

$23.58 

N/A 

N/A 

$7.57 

$19.97 

$9.92 

$17.15 

N/A 

$8.79 

$19.97 

$13.45 

N/A 

N/A 

$13.98 

83904 

Medicare 

Medicaid 

FEHB 1 

FEHB 2 

FEHB 3 

$6.14 

$3.62 

N/A 

N/A 

$268.64 

$23.58 

$18.86 

N/A 

N/A 

$46.50 

$23.58 

$23.58 

N/A 

N/A 

$1,367.08 

$23.58 

$11.72 

N/A 

N/A 

$89.79 

$23.58 

$23.42 

N/A 

$35.01 

$58.72 

83907 

Medicare 

Medicaid 

FEHB 1 

FEHB 2 

FEHB 3 

$18.80 

$11.48 

N/A 

N/A 

$17.88 

$18.80 

$15.04 

N/A 

N/A 

$16.79 

$18.80 

$18.80 

N/A 

$47.60 

$13.12 

$18.80 

$9.33 

N/A 

N/A 

$24.87 

$18.80/$4.95/$18.80* 

$5.54 

N/A 

N/A 

$20.85 

Medicare $6.14 $23.58 $23.58 $23.58 $23.58 

Medicaid $3.75 $18.86 $23.58 $11.71 $23.42 

83909 FEHB 1 N/A $54.12 $18.75 $33.61 $30.27 

FEHB 2 N/A $13.38 $13.49 $13.49 $13.49 

FEHB 3 $23.25 $19.81 $15.61 $16.24 $23.25 

Medicare $5.64 $5.64 $5.64 $5.64 $5.64 

Medicaid $4.43 $4.51 $5.64 $2.80 $20.00 

83912 FEHB 1 N/A $5.25 $5.25 $17.15 $9.47 

FEHB 2 N/A $15.84 $13.18 $5.88 $5.88 

FEHB 3 $36.47 $5.00 $11.46 $5.00 $5.57 

Medicare $6.14 $23.58 $23.58 $23.58 $23.58 

Medicaid $3.75 $18.86 $23.58 $11.71 $23.42 

83914 FEHB 1 N/A $23.94 $33.02 N/A $18.20 

FEHB 2 N/A $13.27 $19.17 $13.68 $13.27 

FEHB 3 $232.50 $383.12 $271.04 $157.95 $232.50 

88271 

Medicare 

Medicaid 

FEHB 1 

FEHB 2 

FEHB 3 

$30.14 

$18.41 

N/A 

N/A 

N/A 

$25.47 

$20.38 

N/A 

N/A 

$109.20 

$30.14 

$30.14 

N/A 

N/A 

$289.02 

$30.14 

$14.97 

$30.00 

N/A 

$155.94 

$25.47/$20.37/$20.37* 

$29.60 

N/A 

N/A 

$150.00 

continued on next page 

* Four States (CA, KS, MO, and NY) are divided into multiple Medicare carrier jurisdictions. Each jurisdiction may have a different price for 

some Current Procedural Terminology codes. In jurisdictions where prices differ, differences are signified using “/” between each 

jurisdiction’s price. 

OEI-07-11-00011 Coverage and Payment for Genetic Laboratory Tests 
 

 

Page 28 – Marilyn Tavenner 

Table D-1: Medicare Clinical Laboratory Fee Schedule, State Medicaid Program, and 

Federal Employee Health Benefit Payment Rates for Selected Genetic Test Codes 

(Continued) 

Current 

Procedural 

Terminology 

Code 

Insurer 

State 

OH OK OR PA RI 

83890 

Medicare 

Medicaid 

FEHB 1 

FEHB 2 

FEHB 3 

$5.64 

$5.37 

N/A 

$28.38 

$5.60 

$5.64 

$5.18 

N/A 

N/A 

$6.60 

$5.64 

$4.25 

N/A 

$9.51 

$4.86 

$5.64 

$5.54 

N/A 

$5.88 

$4.09 

$5.64 

$3.36 

N/A 

N/A 

$10.09 

Medicare $5.64 $5.64 $5.64 $5.64 $5.64 

Medicaid $5.37 $5.18 $4.25 $4.43 $3.36 

83891 FEHB 1 $5.78 $4.76 $5.90 $4.47 N/A 

FEHB 2 $5.88 $2.69 $5.85 $5.88 N/A 

FEHB 3 $2.60 $7.50 $5.71 $4.02 $4.45 

83892 

Medicare 

Medicaid 

FEHB 1 

FEHB 2 

FEHB 3 

$5.64 

$5.37 

N/A 

$6.19 

$8.46 

$5.64 

$5.18 

N/A 

$2.46 

$12.00 

$5.64 

$4.25 

$5.35 

N/A 

$9.90 

$5.64 

$5.00 

N/A 

$5.88 

$9.90 

$5.64 

$3.36 

N/A 

N/A 

$16.20 

83894 

Medicare 

Medicaid 

FEHB 1 

FEHB 2 

FEHB 3 

$5.64 

$5.37 

N/A 

$14.94 

$5.60 

$5.64 

$5.18 

N/A 

$10.64 

$7.84 

$5.64 

$4.25 

N/A 

$17.00 

$16.92 

$5.64 

$5.00 

N/A 

$28.00 

$12.06 

$5.64 

$3.36 

N/A 

N/A 

$16.20 

Medicare $5.64 $5.64 $5.64 $5.64 $5.64 

Medicaid $5.37 $5.18 $4.25 $5.54 $3.36 

83896 FEHB 1 $5.25 N/A N/A $5.46 N/A 

FEHB 2 $5.88 $2.35 $9.01 $5.88 N/A 

FEHB 3 $28.00 $13.55 $9.90 $9.90 $15.65 

83897 

Medicare 

Medicaid 

FEHB 1 

FEHB 2 

FEHB 3 

$5.64 

$5.37 

N/A 

N/A 

$66.27 

$5.64 

$5.18 

N/A 

N/A 

N/A 

$5.64 

$4.25 

N/A 

N/A 

N/A 

$5.64 

$4.43 

N/A 

N/A 

$6.26 

$5.64 

$3.36 

N/A 

N/A 

N/A 

Medicare $23.58 $23.58 $23.58 $23.58 $23.58 

Medicaid $22.47 $21.67 $17.77 $22.50 $14.05 

83898 FEHB 1 $22.65 $22.66 $22.31 $23.53 N/A 

FEHB 2 $35.01 $9.84 $29.85 $35.01 N/A 

FEHB 3 $49.04 $64.86 $28.81 $41.86 $345.60 

Medicare $47.18 $47.18 $47.18 $47.18 $47.18 

Medicaid $45.43 $43.36 $35.53 $37.47 $28.10 

83900 FEHB 1 $12.07 $31.07 $38.25 $12.29 N/A 

FEHB 2 $40.36 $24.57 $61.82 $40.36 N/A 

FEHB 3 $16.82 $30.45 $48.02 $23.92 $13.63 

continued on next page 

OEI-07-11-00011 Coverage and Payment for Genetic Laboratory Tests 
 

 

Page 29 – Marilyn Tavenner 

Table D-1: Medicare Clinical Laboratory Fee Schedule, State Medicaid Program, and 

Federal Employee Health Benefit Payment Rates for Selected Genetic Test Codes 

(Continued) 

Current 

Procedural 

Terminology 

Code 

Insurer 

State 

OH OK OR PA RI 

Medicare $23.58 $23.58 $23.58 $23.58 $23.58 

Medicaid $22.47 $21.67 $17.77 $18.54 $14.05 

83901 FEHB 1 $11.83 $15.65 N/A $12.28 N/A 

FEHB 2 $28.07 $11.27 $22.32 $30.10 N/A 

FEHB 3 $170.51 $119.00 $24.01 $155.65 N/A 

83902 

Medicare 

Medicaid 

FEHB 1 

FEHB 2 

FEHB 3 

$19.97 

$19.02 

N/A 

N/A 

$4.44 

$10.70 

$9.83 

N/A 

$8.33 

$17.52 

$12.09 

$9.11 

N/A 

N/A 

$9.90 

$19.97 

N/A 

N/A 

$36.60 

$19.00 

$7.62 

$4.54 

N/A 

N/A 

$6.42 

Medicare $23.58 $23.58 $23.58 $23.58 $23.58 

Medicaid $22.47 $21.67 $17.77 $18.54 $14.05 

83904 FEHB 1 N/A N/A N/A $23.54 N/A 

FEHB 2 N/A N/A $18.50 $35.01 N/A 

FEHB 3 $293.40 $38.64 N/A $89.79 N/A 

83907 

Medicare 

Medicaid 

FEHB 1 

FEHB 2 

FEHB 3 

$16.24 

$15.64 

N/A 

N/A 

$9.18 

$18.35 

$16.87 

N/A 

N/A 

$15.44 

$18.80 

$14.16 

$58.80 

N/A 

$16.21 

$18.80 

$14.93 

N/A 

N/A 

$17.88 

$18.80 

$11.20 

N/A 

N/A 

$33.63 

Medicare $23.58 $23.58 $23.58 $23.58 $23.58 

Medicaid $22.72 $21.67 $17.77 $18.74 $14.05 

83909 FEHB 1 $6.03 $30.26 $29.51 $6.13 N/A 

FEHB 2 $12.26 $12.26 $16.70 $9.51 N/A 

FEHB 3 $11.65 $23.25 $40.68 $11.96 $345.60 

Medicare $5.64 $5.64 $5.64 $5.64 $5.64 

Medicaid $5.37 $5.18 $4.25 $5.54 $3.36 

83912 FEHB 1 $5.25 $10.73 $5.46 $4.19 N/A 

FEHB 2 $5.88 $2.92 $33.32 $5.88 N/A 

FEHB 3 $6.10 $7.84 $34.17 $20.78 $5.50 

Medicare $23.58 $23.58 $23.58 $23.58 $23.58 

Medicaid $22.72 $21.67 $17.77 N/A $14.05 

83914 FEHB 1 $6.03 $27.09 $26.71 $6.14 N/A 

FEHB 2 $12.69 $12.28 $24.14 $12.26 N/A 

FEHB 3 $210.25 $232.50 $117.38 $383.12 $5.88 

88271 

Medicare 

Medicaid 

FEHB 1 

FEHB 2 

FEHB 3 

$30.14 

$28.71 

$28.46 

N/A 

$18.62 

$30.14 

$27.70 

N/A 

N/A 

$191.72 

$30.14 

$22.70 

N/A 

N/A 

$26.52 

$16.97 

N/A 

N/A 

N/A 

$150.36 

$30.14 

$17.96 

N/A 

N/A 

N/A 

continued on next page 

OEI-07-11-00011 Coverage and Payment for Genetic Laboratory Tests 
 

 

Page 30 – Marilyn Tavenner 

Table D-1: Medicare Clinical Laboratory Fee Schedule, State Medicaid Program, and 

Federal Employee Health Benefit Payment Rates for Selected Genetic Test Codes 

(Continued) 

Current 

Procedural 

Terminology 

Code 

Insurer 

State 

SC SD TN TX UT 

Medicare $5.64 $5.64 $5.64 $5.64 $4.48 

Medicaid $5.03 $5.54 N/A $5.51 $3.85 

83890 FEHB 1 $3.36 $51.82 N/A $9.82 $5.94 

FEHB 2 N/A N/A N/A $36.00 $19.23 

FEHB 3 $5.00 $8.25 $4.93 $5.00 $5.00 

Medicare $5.64 $5.64 $5.64 $5.64 $4.48 

Medicaid $5.03 $5.54 N/A $5.51 $4.33 

83891 FEHB 1 $5.94 $34.52 $5.86 $5.86 $5.94 

FEHB 2 $4.64 N/A $24.00 $5.88 $5.88 

FEHB 3 $4.95 $4.95 $4.95 $4.86 $5.00 

Medicare $5.64 $5.64 $5.64 $5.64 $4.48 

Medicaid $5.03 $5.54 N/A $5.51 $3.85 

83892 FEHB 1 $5.18 $33.02 $5.60 $5.94 $5.19 

FEHB 2 N/A N/A $5.88 $12.75 $5.88 

FEHB 3 $9.90 $9.90 $9.90 $9.90 $7.63 

Medicare $5.64 $5.64 $5.64 $5.64 $4.48 

Medicaid $5.03 $5.54 N/A $5.51 $3.85 

83894 FEHB 1 N/A $58.20 $5.94 $5.19 $5.94 

FEHB 2 N/A N/A N/A $24.00 $24.00 

FEHB 3 $9.00 $15.00 $5.00 $6.88 $5.00 

Medicare $5.64 $5.64 $5.64 $5.64 $4.48 

Medicaid $5.03 $5.54 N/A $5.51 $4.22 

83896 FEHB 1 $5.46 $20.26 $5.25 $11.77 $11.75 

FEHB 2 $5.04 N/A N/A $6.02 $17.46 

FEHB 3 $9.90 $8.25 $13.49 $19.80 $9.12 

83897 

Medicare 

Medicaid 

FEHB 1 

FEHB 2 

FEHB 3 

$5.64 

$5.03 

N/A 

N/A 

N/A 

$5.64 

$5.54 

N/A 

N/A 

N/A 

$5.64 

N/A 

N/A 

N/A 

$7.03 

$5.64 

$5.51 

N/A 

N/A 

$7.33 

$4.48 

$4.33 

N/A 

N/A 

N/A 

Medicare $23.58 $23.58 $5.80 $14.32 $20.95 

Medicaid $21.04 $23.17 N/A $14.00 $18.56 

83898 FEHB 1 $25.96 $58.20 $24.85 $24.85 $24.85 

FEHB 2 $17.05 N/A $317.89 $35.01 $35.51 

FEHB 3 $47.10 $34.53 $7.08 $20.69 $23.17 

Medicare $47.18 $47.18 $11.58 $28.65 $41.87 

Medicaid $42.10 $46.84 N/A $27.99 N/A 

83900 FEHB 1 $38.91 N/A $70.35 $49.69 $108.00 

FEHB 2 $147.00 N/A $38.92 $29.89 $40.36 

FEHB 3 $20.83 $28.68 $8.25 $16.94 $41.49 

continued on next page 

OEI-07-11-00011 Coverage and Payment for Genetic Laboratory Tests 
 

 

Page 31 – Marilyn Tavenner 

Table D-1: Medicare Clinical Laboratory Fee Schedule, State Medicaid Program, and 

Federal Employee Health Benefit Payment Rates for Selected Genetic Test Codes 

(Continued) 

Current 

Procedural 

Terminology 

Code 

Insurer 

State 

SC SD TN TX UT 

Medicare $23.58 $23.58 $5.80 $14.32 $20.95 

Medicaid $21.04 $23.17 N/A $14.00 $20.29 

83901 FEHB 1 $24.80 N/A N/A $18.54 $22.32 

FEHB 2 $21.08 N/A $34.01 $12.26 N/A 

FEHB 3 $100.49 $18.25 $59.59 $110.11 $125.58 

83902 

Medicare 

Medicaid 

FEHB 1 

FEHB 2 

FEHB 3 

$19.97 

$17.82 

N/A 

N/A 

$31.00 

$19.97 

$19.61 

N/A 

N/A 

$9.90 

$5.80 

N/A 

$5.26 

N/A 

$4.57 

$14.32 

$14.00 

$29.65 

N/A 

$16.94 

$19.97 

$46.89 

$23.54 

N/A 

$25.00 

Medicare $23.58 $23.58 $5.80 $14.32 $20.95 

Medicaid $21.04 $23.17 N/A $14.00 $20.29 

83904 FEHB 1 $14.05 N/A N/A $22.66 $20.60 

FEHB 2 $13.02 N/A N/A $35.01 N/A 

FEHB 3 $54.42 N/A $15.34 $64.14 $134.69 

83907 

Medicare 

Medicaid 

FEHB 1 

FEHB 2 

FEHB 3 

$18.80 

$16.77 

N/A 

N/A 

$17.55 

$18.80 

$18.66 

N/A 

N/A 

N/A 

$18.80 

N/A 

N/A 

N/A 

$18.53 

$18.80 

$18.36 

N/A 

N/A 

$16.21 

$18.80 

N/A 

N/A 

N/A 

$17.88 

Medicare $23.58 $23.58 $5.80 $14.32 $20.95 

Medicaid $21.04 $23.42 N/A $14.00 N/A 

83909 FEHB 1 $22.95 $168.89 $35.18 $24.85 $18.75 

FEHB 2 $13.02 N/A $18.74 $12.26 $13.49 

FEHB 3 $13.32 $21.50 $5.90 $8.47 $20.45 

Medicare $5.64 $5.64 $5.64 $5.64 $4.48 

Medicaid $5.03 $5.54 N/A $5.51 $4.33 

83912 FEHB 1 $5.36 $56.58 $5.36 $5.36 $5.94 

FEHB 2 $11.09 N/A $17.64 $5.88 $5.88 

FEHB 3 $4.95 $7.00 $5.00 $4.95 $5.00 

Medicare $23.58 $23.58 $5.80 $14.32 $20.95 

Medicaid $21.04 $23.42 N/A $14.00 N/A 

83914 FEHB 1 $24.85 N/A N/A $24.85 $34.17 

FEHB 2 $73.80 N/A $18.74 $12.28 $19.17 

FEHB 3 $234.20 $219.00 $132.16 $271.04 $82.88 

88271 

Medicare 

Medicaid 

FEHB 1 

FEHB 2 

FEHB 3 

$30.14 

$26.89 

N/A 

N/A 

$179.60 

$30.14 

$3.50 

N/A 

N/A 

$37.00 

$20.37 

N/A 

N/A 

N/A 

$63.23 

$30.14 

$29.45 

N/A 

N/A 

$107.67 

$20.37 

$19.73 

$30.00 

N/A 

$127.32 

continued on next page 

OEI-07-11-00011 Coverage and Payment for Genetic Laboratory Tests 
 

 

Page 32 – Marilyn Tavenner 

Table D-1: Medicare Clinical Laboratory Fee Schedule, State Medicaid Program, and 

Federal Employee Health Benefit Payment Rates for Selected Genetic Test Codes 

(Continued) 

Current 

Procedural 

Terminology 

Code 

Insurer 

State 

VA VT WA WI WV WY 

Medicare $5.51 $5.64 $5.64 $5.64 $5.64 $5.64 

Medicaid $5.14 $5.40 $5.74 $5.60 $5.08 $5.04 

83890 FEHB 1 N/A N/A $5.25 N/A N/A N/A 

FEHB 2 $1.98 N/A $4.40 $45.00 N/A N/A 

FEHB 3 $4.95 $5.45 $5.00 $8.36 $7.20 N/A 

Medicare $5.51 $5.64 $5.64 $5.64 $5.64 $5.64 

Medicaid $5.14 $5.40 $5.74 $5.60 $5.08 N/A 

83891 FEHB 1 $5.79 N/A $5.78 N/A $5.78 N/A 

FEHB 2 $5.88 N/A $5.88 $26.95 $24.00 N/A 

FEHB 3 $5.00 $16.08 $5.17 $6.31 $7.20 $5.91 

Medicare $5.51 $5.64 $5.64 $5.64 $5.64 $5.64 

Medicaid $5.14 $5.40 $5.74 $5.60 $5.08 $5.04 

83892 FEHB 1 $5.25 N/A $5.25 N/A N/A N/A 

FEHB 2 $5.88 N/A $13.02 $14.64 N/A N/A 

FEHB 3 $9.90 $16.62 $14.85 $5.74 $14.40 $9.72 

Medicare $5.51 $5.64 $5.64 $5.64 $5.64 $5.64 

Medicaid $5.14 $5.40 $5.74 $5.60 $5.08 $5.04 

83894 FEHB 1 $5.70 N/A N/A N/A $5.26 N/A 

FEHB 2 $5.45 N/A $24.00 $52.37 N/A N/A 

FEHB 3 $5.09 $16.62 $16.92 $5.74 $14.40 $13.90 

Medicare $5.51 $5.64 $5.64 $5.64 $5.64 $5.64 

Medicaid $5.14 $5.40 $5.74 $5.60 $5.08 $5.04 

83896 FEHB 1 $5.25 N/A $5.25 N/A N/A N/A 

FEHB 2 $5.88 N/A $8.27 $25.20 N/A N/A 

FEHB 3 $19.80 $337.94 $10.03 $11.01 $43.20 $11.14 

83897 

Medicare 

Medicaid 

FEHB 1 

FEHB 2 

FEHB 3 

$5.51 

$5.14 

N/A 

$10.14 

$4.95 

$5.64 

$5.40 

N/A 

N/A 

N/A 

$5.64 

$5.74 

N/A 

N/A 

N/A 

$5.64 

$5.60 

N/A 

N/A 

N/A 

$5.64 

$5.08 

N/A 

N/A 

N/A 

$5.64 

$5.04 

N/A 

N/A 

N/A 

Medicare $23.58 $6.14 $23.58 $23.58 $23.58 $23.58 

Medicaid $18.53 $5.93 $24.01 $3.73 $21.22 $21.08 

83898 FEHB 1 $23.53 N/A N/A N/A N/A N/A 

FEHB 2 $19.91 N/A $35.01 $102.06 $35.01 N/A 

FEHB 3 $18.14 $44.90 $39.53 $24.01 $29.25 $345.60 

Medicare $47.18 $12.29 $47.18 $47.18 $47.18 $47.18 

Medicaid $44.50 $34.86 $36.50 $42.58 $42.46 $42.16 

83900 FEHB 1 $28.25 N/A $101.83 N/A $46.55 N/A 

FEHB 2 $40.36 N/A $46.84 $202.75 $37.47 N/A 

FEHB 3 $5.18 $46.50 $44.82 $46.50 $58.50 $47.34 

continued on next page 

OEI-07-11-00011 Coverage and Payment for Genetic Laboratory Tests 
 

 

Page 33 – Marilyn Tavenner 

Table D-1: Medicare Clinical Laboratory Fee Schedule, State Medicaid Program, and 

Federal Employee Health Benefit Payment Rates for Selected Genetic Test Codes 

(Continued) 

Current 

Procedural 

Terminology 

Code 

Insurer 

State 

VA VT WA WI WV WY 

Medicare $23.58 $6.14 $23.58 $23.58 $23.58 $23.58 

83901 Medicaid 

FEHB 1 

$13.37 

$15.06 

$5.93 

N/A 

$24.01 

N/A 

$23.40 

N/A 

$21.22 

$24.76 

$21.08 

N/A 

FEHB 2 $21.40 N/A $4.00 $51.82 $34.01 N/A 

FEHB 3 $70.00 N/A $93.91 $26.41 $351.00 $162.72 

83902 

Medicare 

Medicaid 

FEHB 1 

FEHB 2 

FEHB 3 

$5.51 

$5.14 

$13.63 

N/A 

$8.58 

$5.80 

$5.57 

N/A 

N/A 

$19.00 

$12.09 

$12.31 

$5.26 

N/A 

$9.90 

$14.53 

$14.41 

N/A 

N/A 

$31.00 

$19.97 

$17.97 

$5.26 

N/A 

$9.90 

$19.97 

$17.85 

N/A 

N/A 

$31.00 

Medicare $23.58 $6.14 $23.58 $23.58 $23.58 $23.58 

Medicaid $13.37 $5.93 $24.01 $23.40 $21.22 $21.08 

83904 FEHB 1 $22.66 N/A N/A N/A $22.66 N/A 

FEHB 2 $29.00 N/A $24.02 N/A N/A N/A 

FEHB 3 $54.42 $67.35 $134.69 $34.41 $81.36 N/A 

83907 

Medicare 

Medicaid 

FEHB 1 

FEHB 2 

FEHB 3 

$16.36 

$15.43 

N/A 

N/A 

$16.21 

$18.80 

$34.86 

N/A 

N/A 

$17.88 

$18.80 

$14.54 

N/A 

N/A 

$17.88 

$10.51 

$9.49 

N/A 

N/A 

N/A 

$18.80 

$16.92 

N/A 

N/A 

N/A 

$12.27 

$10.96 

N/A 

N/A 

$24.32 

Medicare $23.58 $6.14 $23.58 $23.58 $23.58 $23.58 

Medicaid $22.25 $5.93 $18.25 $21.29 $21.22 $21.08 

83909 FEHB 1 $18.74 N/A N/A N/A $23.25 N/A 

FEHB 2 $13.49 N/A $16.75 $17.12 $18.74 N/A 

FEHB 3 $2.59 $34.08 $33.17 $34.95 $29.25 $345.60 

Medicare $5.51 $5.64 $5.64 $5.64 $5.64 $5.64 

Medicaid $5.20 N/A $5.74 $5.60 $5.08 $5.04 

83912 FEHB 1 $5.25 N/A $5.25 N/A $5.25 N/A 

FEHB 2 $5.88 N/A $5.88 $54.95 $40.00 N/A 

FEHB 3 $5.00 $42.82 $5.64 $6.31 $29.25 $5.57 

Medicare $23.58 $6.14 $23.58 $23.58 $23.58 $23.58 

Medicaid $22.25 $34.86 $18.25 $21.29 $21.22 $21.08 

83914 FEHB 1 $15.13 N/A N/A N/A N/A N/A 

FEHB 2 $19.17 N/A $6.00 N/A $18.74 N/A 

FEHB 3 $82.88 $479.26 $229.04 $102.35 $294.03 $99.37 

88271 

Medicare 

Medicaid 

FEHB 1 

FEHB 2 

FEHB 3 

$30.14 

$28.12 

$28.45 

N/A 

$69.03 

$30.14 

$38.34 

N/A 

N/A 

N/A 

$30.14 

$23.32 

N/A 

N/A 

$116.95 

$20.37 

$20.22 

N/A 

N/A 

$25.00 

$30.14 

$27.13 

$28.45 

N/A 

$138.88 

$30.14 

$26.94 

N/A 

N/A 

$239.44 

Source: Office of Inspector General analysis of Medicare Clinical Laboratory Fee Schedule, State Medicaid Program, and FEHB Payment 

Rates, 2011. 

OEI-07-11-00011 Coverage and Payment for Genetic Laboratory Tests 
 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Page 34 – Marilyn Tavenner 

APPENDIX E 

Table E-1: State Medicaid Program Payment Rates for Selected Genetic Tests by Test 

Name 

Test State 

CA DE IL IA MA MN PA VA 

BCR/ABL1 

Translocation 

Analysis 

$867 

BRCA1 Gene 

Analysis $3,340 $3,120 $3,030 $4,498 $2,731 $1,000 $3,120 

BRCA2 Gene 

Analysis $3,340 $3,120 $2,770 $4,947 $1,000 

CFTR Gene 

Analysis $180 

ChemoFx $1,408 

F2 Gene 

Analysis $132 

KRAS Gene 

Analysis $421 

MLH1 Gene 

Analysis 

MSH2 Gene 

Analysis 

OncoTypeDX $2,050 $3,416 

PathFinderTG $2,732 

Pathwork Tissue 

of Origin $927 

VeriStrat $25 

Note: Payment rates rounded to the nearest whole dollar. 

Source: Office of Inspector General analysis of State Medicaid program survey responses, 2011.
 

OEI-07-11-00011 Coverage and Payment for Genetic Laboratory Tests 
 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Page 35 – Marilyn Tavenner 

APPENDIX F 

Table F-1: Federal Employee Health Benefits Plan Median Payment Rates for Selected 

Genetic Tests by Test Name 

State 

Test 

AlloMap 

BCR/ABL1 

Translocation 

Analysis 

CFTR 

Gene 

Analysis 

ChemoFx F2 Gene 

Analysis 

HFE 

Gene 

Analysis 

Alabama $13 $95 

Alaska $187 

Arizona $20 $18 $75 

Arkansas $150 

California $50 $18 $105 

Colorado $11 $93 

Connecticut $38 $114 $38 

Delaware $13 $92 

District of Columbia $6 $18 $73 

Florida $117 $7 $98 

Georgia $177 $95 

Hawaii $109 

Idaho $130 

Illinois $80 $93 $12 $99 

Indiana $455 $72 

Iowa $227 $150 

Kansas $270 $124 

Kentucky $18 $35 $57 

Louisiana $171 $126 

Maine $42 $65 

Maryland $8 $12 $73 

Massachusetts $98 

Michigan $102 $60 

Minnesota $16 $1 $125 

Mississippi $131 

Missouri $130 $105 

Montana $88 

Nebraska $132 

Nevada $2 $12 $116 

New Hampshire $125 

New Jersey $90 $13 $101 

New Mexico $207 $88 

New York $10 $86 

North Carolina $10 $30 $95 

North Dakota $115 $93 $168 $7 

Ohio $35 $35 $83 $14 

Oklahoma $8 $10 $131 

Oregon $40 $27 $121 $9 $6 

Pennsylvania $90 $54 

Rhode Island $3,658 $106 

South Carolina $9 $123 

South Dakota $788 $187 

Tennessee $131 $26 

Texas $9 $6 $115 

Utah $53 $9 

Vermont $182 

Virginia $428 $18 $88 $9 

Washington $47 $124 $8 

West Virginia $8 $7 $93 

Wisconsin $758 $6 $143 $51 

Wyoming $130 

continued on next page 

Note: Payment rates rounded to the nearest whole dollar. 

OEI-07-11-00011 Coverage and Payment for Genetic Laboratory Tests 
 

 

 

 

 

 

 

 

 

 

 

Page 36 – Marilyn Tavenner 

APPENDIX F 

Table F-1: Federal Employee Health Benefits Plan Median Payment Rates for Selected 

Genetic Tests by Test Name (Continued) 

State 

Test 

MSH2 

Gene 

Analysis 

Oncotech 

EDR PathFinderTG 

Pathwork 

Tissue of 

Origin 

VeriStrat 

Alabama $276 $240 $10 $8 

Alaska $38 

Arizona $5,640 $5,640 $10 $20 

Arkansas $3,760 $3,760 $8 

California $70 $70 $18 $50 

Colorado $3,760 $1,885 $10 $11 

Connecticut $14 

Delaware $13 $17 $13 

District of Columbia $25 $15 $5 $6 

Florida $3,760 $3,760 $19 $48 

Georgia $232 $5,640 $10 

Hawaii $44 $44 $14 

Idaho $18 

Illinois $360 $60 $17 $29 

Indiana $5,170 $4,935 $15 $455 

Iowa $65 $1,880 $422 $14 $227 

Kansas $198 $422 $18 $422 

Kentucky $138 $18 $12 $18 

Louisiana $9 $9 $16 $171 

Maine $42 $6 

Maryland $470 $66 $10 $8 

Massachusetts $16 

Michigan $102 $27 $102 

Minnesota $313 $286 $15 $16 

Mississippi $5,640 $5,640 $20 

Missouri $130 $422 $18 $422 

Montana $19 

Nebraska $8 $8 $10 

Nevada $1,207 $8 $5 $10 $2 

New Hampshire $27 

New Jersey $3,029 $418 $17 $90 

New Mexico $207 $11 

New York $3,760 $62 $15 $10 

North Carolina $10 $10 $10 

North Dakota $113 $115 $27 $115 

Ohio $767 $35 $17 $35 

Oklahoma $13 $8 $17 $8 

Oregon $40 $21 $40 

Pennsylvania $1,880 $93 $18 $90 

Rhode Island $2,350 $3,004 $14 $3,658 

South Carolina $5,640 $9 $11 $9 

South Dakota $774 $760 $10 

Tennessee $3,055 $3,055 $10 

Texas $940 $940 $10 $9 

Utah $10 

Vermont $28 

Virginia $686 $2,820 $8 $1,869 

Washington $5,640 $5,640 $15 

West Virginia $8 $29 $8 

Wisconsin $462 $758 $11 $758 

Wyoming $1,443 $1,443 $15 

Source: Office of Inspector General analysis of Federal Employee Health Benefits plan payment rates, 2011. 

OEI-07-11-00011 Coverage and Payment for Genetic Laboratory Tests