Health Information Management

Q&A: How should we bill lab tests that should be paid separately?

APCs Insider, May 9, 2014

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Q: We are having a lot of issues in moving laboratory testing to a 14X bill type when they should be paid separately. Can this be done in a different manner?
A: For the time being, payment for clinical laboratory tests is made separately under the OPPS only if reported on a 14X bill type. However, this will change beginning July 1. CMS will be issuing a modifier that should be appended to clinical laboratory tests that meet the criteria for separate payment under the OPPS.
According toMLN Matters® 1412, beginning July 1, providers should report any laboratory test that should receive separate payment with the modifier for dates of service after January 1, 2014; bill type 14X will return to being used for referred specimens only.
The criteria are the same that were published in the 2014 OPPS final rule:
  • Non-patient (referred) specimen.
  • A hospital collects a specimen and furnishes only the outpatient labs on a given date of service.
  • A hospital conducts outpatient lab tests that are clinically unrelated to other hospital outpatient services furnished the same day. "Unrelated" means the laboratory test is ordered by a different practitioner than the practitioner who ordered the other hospital outpatient services, for a different diagnosis.
 CMS adds in the MLN Matters article:
It will continue to be the hospital's responsibility to determine when laboratory tests qualify to receive separate payment. Starting with claims received July 1, 2014, and after, when a hospital appends the new modifier to a laboratory service, the provider is attesting that exception (2) or (3) listed above is met. The requirement for all OPPS services to be submitted on a single 13x claim (other than recurring services) continues to apply.
CMS also provides some billing scenarios related to clinical laboratory testing and application of the new modifier.
Editor’s note: Denise Williams, RN, CPC-H, vice president of revenue integrity services at Health Revenue Assurance Associates, Inc., in Plantation, Fla., answered this question.

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