36.4.22 Laboratory ServicesTexas Medicaid Program benefits are provided for professional and technical services ordered by a physician and provided under the personal supervision of a physician in a setting other than a hospital (inpatient or outpatient). All laboratory services must be documented in the patient's medical record as medically necessary and referenced to an appropriate diagnosis. Medicaid does not reimburse baseline or screening laboratory studies. If a physician performs more than 100 laboratory tests per year for other providers in their laboratory, the laboratory must be certified by Medicare, and the provider must enroll as an independent laboratory with TMHP. A physician laboratory is defined as one owned by the physician, located in the office area, and the laboratory where the physician performs or personally supervises laboratory tests daily. Personal supervision means the physician must be in the building of the office or facility when and where the service is provided. All required THSteps laboratory work is to be performed by the DSHS Laboratory Services Section. DSHS makes these services available free to all enrolled THSteps medical providers for THSteps medical check ups only. THSteps services provided in a private laboratory will not be reimbursed. The Laboratory Services Section is reimbursed at its cost for performing these tests. Exception: THSteps laboratory specimens for blood test screening for hyperlipidemia or Type 2 diabetes may be sent to the provider's laboratory of choice. Except for Pap smear screenings for hyperlipidemia or Type 2 diabetes, all required THSteps laboratory specimens that can be mailed at ambient temperature must be sent through the U.S. Postal Service using the provided business reply labels to the DSHS Laboratory Services Section at:
DSHS Laboratory Services Section THSteps laboratory work that requires overnight shipping on cold packs through a courier service must be sent to the DSHS Laboratory Services Section at:
DSHS Laboratory Services Section Pap smear specimens must be sent to the following address:
Women's Health Laboratories Refer to: "Laboratory Services" for more information. Only physicians may bill for laboratory tests that are actually provided in their office. Any test sent to an outside laboratory should not be billed on the physician's claim. The laboratory bills Medicaid directly for the tests it performs. A physician may bill a laboratory handling fee (1-99000) if the specimen is obtained by venipuncture or catheterization and sent to an outside lab. The identity of the laboratory must be listed on the claim form. The laboratory handling fee covers the expense of obtaining and packaging the specimen to a reference laboratory. Providers may be reimbursed one laboratory handling fee a day per client, unless multiple specimens are obtained and sent to different laboratories. When billing for a laboratory handling fee, the physician must document that a specimen was sent to a reference laboratory in Block 20 of the CMS-1500 claim form and indicate the reference laboratory name and address or provider identifier in the appropriate field of the electronic claim form or Block 32 of the CMS-1500 paper claim form. The physician is required to forward the client's name, address, Medicaid number, and diagnosis, if appropriate, with the specimen to the reference laboratory so the laboratory may bill the Texas Medicaid Program for its services. A physician may bill only one laboratory handling fee per client visit unless the specimen is divided and sent to different laboratories or different specimens are collected and sent to different labs. The claim must indicate the name and/or address of each laboratory to which a specimen is sent for more than one laboratory handling fee to be paid. This limitation does not apply to THSteps medical check up providers who must submit specimens to the DSHS Laboratory. Interpretation of laboratory tests for patients is considered part of the physician's professional services (hospital, office, or emergency room visits) and should not be billed separately. Laboratory tests generally considered part of a laboratory panel (chemistries, complete blood counts [CBCs], urinalyses [UAs] and performed on the same day must be billed as a panel regardless of the method used to perform the tests [automated or manual]). Hospital reimbursements (i.e., inpatient DRG reimbursement) include payment for all pathology and laboratory services, including those sent to referral laboratories. Hospital-based and referral laboratory providers must obtain reimbursement for the technical portion from the hospital. The technical portion includes the handling of specimens and the automated or technician-generated reading and reporting of results. These services are not billable to Medicaid-covered clients. Physician interpretations, that are requested of a consulting pathologist and require professional reading and reporting of results, may be billed to the Texas Medicaid Program separately as a professional charge. All providers of laboratory services must comply with the rules and regulations of CLIA. Providers not complying with CLIA cannot be reimbursed for laboratory services. The Deficit Reduction Act (DEFRA) of 1984 limited reimbursement of clinical laboratory services provided by a physician laboratory or an independent laboratory to a national fee schedule. Refer to: "Laboratory Paneling" for claims processing instructions. "Clinical Laboratory Improvement Amendments (CLIA)" . |
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Texas Medicaid & Healthcare Partnership CPT only copyright 2007 American Medical Association. All rights reserved. |
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