CSHCN 2008 > Physician > Benefits and Limitations

24.3.21 Laboratory Services

To be reimbursed by the CSHCN Services Program, all clinical laboratory services, including those located in physician's offices, must comply with the rules and regulations of the CLIA of 1988.

Refer to: Section 3.2.10, "Clinical Laboratory Improvement Amendments (CLIA) of 1988," on page 3-10 and Section 19.2, "Clinical Laboratory Improvement Amendments (CLIA) of 1988," on page 19-2 for additional information regarding CLIA regulations.

If a physician performs more than 100 laboratory tests per year for other providers in his or her laboratory, the lab 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 is the laboratory in which the physician performs or personally supervises laboratory tests on a daily basis. Personal supervision is defined as the presence of the physician in the building where the services are performed.

CSHCN Services Program benefits are provided for medically necessary professional and/or technical services ordered by a practitioner who is licensed to do so and provided under the personal supervision of a physician. All laboratory services must be documented in the client's medical record as medically necessary and referenced to an appropriate diagnosis.

Laboratory tests generally performed as a panel (chemistries, complete blood counts [CBCs], or urinalyses [UAs]) and performed on the same day by the same provider must be billed as a panel regardless of the method used to perform the test.

Physicians may bill only for laboratory tests that are actually performed in their office. If a specimen is obtained by venipuncture or catheterization and forwarded to an outside laboratory, the physician may bill only a lab handling fee (procedure code 1-99000).

The lab handling fee covers the expense of obtaining the specimen and packaging it to be sent to a reference laboratory. When billing for a lab 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 CSHCN Services Program provider identifier in Block 32 of the CMS-1500 claim form. The physician is required to forward the client's name, address, client number, and diagnosis with the specimen to the reference laboratory so that the laboratory may bill the CSHCN Services Program for its services. When billing for laboratory services, providers should use the date the specimen was collected as the date of service. If the specimen is sent to a reference laboratory and the client is an inpatient, the hospital is responsible for payment of these services to the reference laboratory.

Providers may be reimbursed one lab handling fee per day per client, unless multiple specimens are obtained and sent to different laboratories.

Interpretation of laboratory tests for patients is considered part of a physician's professional services (hospital, office, or emergency room visits) and must not be billed separately.

Providers who perform both the technical service and interpretation must bill for the total component. Providers who perform only the technical service must bill for the technical component. Providers who perform only the interpretation must bill for the interpretation component. Claims filed in excess of the amount allowed for the total component for the same procedure, same dates of service, same client, by any provider, are denied. Claims are paid based on the order in which they are received. For example, if a claim is received for the total component and TMHP has already made payment for the technical and/or interpretation component for the same procedure, same dates of services, same client, by any provider, the claim for the total component is denied as previously paid to another provider. The same is true if a total component has already been paid and claims are received for the individual components.

Clinical pathology services furnished to hospital inpatients and outpatients by physicians are not reimbursable by the CSHCN Services Program. Anatomical pathology services to hospital patients continue to be allowed for CSHCN Services Program reimbursement.

If a physician is personally involved in a clinical pathology procedure, a clinical pathology consultation may be billed using either procedure codes 3-80500 or 3-80502 for pathology consultation.

To be considered for payment, all clinical pathology consultations must meet all the following criteria:

•Be requested by the patient's attending physician.

•Relate to a test result that lies outside the expected range in view of the condition of the client.

•Result in a narrative report included in the patient's medical record that documents direct physician contact with the client.

•Require that medical judgment be exercised by the physician performing the consultation.

Refer to: Chapter 19, "Laboratory Services," for additional information concerning coding and reimbursement for laboratory procedures.