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O.4.2.3 Laboratory Services
Medicaid family planning service providers must document all laboratory services ordered in the client's medical record as medically necessary and reference an appropriate diagnosis. Any test specimen sent to a laboratory for interpretation should not be billed on the family planning provider's claim. The laboratory bills the Texas Medicaid Program directly for the tests the laboratory performs.
All providers of laboratory services must comply with the rules and regulations of the Clinical Laboratory Improvement Amendments (CLIA). Providers not complying with CLIA will not be reimbursed for laboratory services. Only the office or lab actually performing the laboratory test procedure and holding the appropriate CLIA certificate may bill for the procedure.
A provider that does not perform the laboratory procedure may be reimbursed one lab-handling fee per day, per client, unless multiple specimens are obtained and sent to different laboratories. Procedure code 1-99000 with modifier FP is paid for handling and/or conveyance of the specimen for transfer from the physician's office to a laboratory.
Handling fees are not paid for Pap smears or cultures. When billing for Pap smear interpretations, the claim must indicate that the screening and interpretation were actually performed in the office (place of service [POS] 1) by using the modifier SU, Procedure performed in physician's office (e.g., 5-88150-SU).
Providers must forward the client's name, address, Medicaid number, and a family planning diagnosis with any specimen, including Pap smears, to the reference laboratory so the laboratory may bill the WHP for its family planning lab services.
When family planning test specimens, such as Pap smears, are collected, providers must direct the laboratory to indicate that the claim for the test is to be billed as a family planning service (i.e., procedure must be billed with a WHP diagnosis).
The following is a list of laboratory procedures and reimbursement amounts authorized for billing by Title XIX family planning service providers with appropriate documentation in the client record. This list is not all-inclusive:
Procedure code 5-87797 will be denied if submitted for the same date of service as procedure code 5-87800. Providers are reminded to code to the highest level of specificity with a diagnosis to support medical necessity when submitting procedure code 5-87797. Claims may be subject to retrospective review if they are submitted with diagnosis codes that do not support medical necessity.
If more than one of procedure codes 5-87480, 5-87510, 5-87660, or 5-87800 is submitted by the same provider for the same client with the same date of service, all of the procedure codes will be denied.
Procedure codes 5-87480, 5-87510, 5-87660, 5-87797, and 5-87800 are not payable in the inpatient hospital setting.
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