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December 2016 Texas Medicaid Provider Procedures Manual

Clinics and Other Outpatient Facility Services Handbook : 6 Renal Dialysis Facility : 6.2 Services, Benefits, Limitations, and Prior Authorization : 6.2.9 Laboratory and Radiology Services : In-Facility Dialysis—Routine Laboratory
Laboratory testing may be obtained and processed in the renal dialysis facility or by an outside laboratory. Charges for routine laboratory tests performed according to the established frequencies in the following tables are included in the facility’s composite rate submitted to Texas Medicaid regardless of where tests were processed. If the routine laboratory testing is processed by an outside laboratory, the outside laboratory will bill the renal dialysis facility. The renal dialysis facility will then submit a claim to Texas Medicaid unless the test results are inclusive tests.
If additional in-facility laboratory testing is medically necessary beyond the routine frequencies identified below, providers must bill with modifier 91 to indicate the billed laboratory procedure is medically necessary. The billing provider must also submit documentation supporting the medical necessity with the claim and maintain the documentation in the client’s medical record.
Modifier 91 is used to indicate that a test was performed more than once on the same day for the same client only when it is necessary to obtain multiple results in the course of the treatment. This modifier may not be used to indicate any of the following:
When there are standard Healthcare Common Procedure Coding System (HCPCS) codes available that describe the series of results (e.g., glucose tolerance tests, evocative/suppression testing, etc.).
Modifier 91 may only be used for laboratory tests paid under the clinical diagnostic laboratory fee schedule.
Per Dialysis
Per Week
Per Month
The routine tests listed in the previous tables are frequently performed as an automated battery of tests such as the sequential multi-channel analysis with computer (SMAC)‑12 (chemistry panels). These tests are considered routine and are included in the charge for dialysis, unless there is an additional diagnosis to document medical necessity for performing the tests in excess of the recommended frequencies.

Texas Medicaid & Healthcare Partnership
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