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December 2016 Texas Medicaid Provider Procedures Manual

Medical and Nursing Specialists, Physicians, and Physician Assistants Handbook : 9 Physician : 9.2 Services, Benefits, Limitations, and Prior Authorization : 9.2.40 Laboratory Services

9.2.40
Texas Medicaid benefits are provided for professional and technical services ordered by a physician and provided under the supervision of a physician in a setting other than a hospital (inpatient or outpatient). All laboratory services must be documented in the client’s medical record as medically necessary and referenced to an appropriate diagnosis. Texas Medicaid does not reimburse baseline or screening laboratory studies.
Providers may bill only for laboratory tests that are actually provided in their office. Any test sent to an outside laboratory must not be billed on the provider’s claim. Laboratories bill Texas Medicaid directly for the tests they perform.
Unless otherwise noted, interpretation of laboratory tests is considered part of the provider’s professional services (hospital, office, or emergency room visits) and must not be billed separately. Modifier Q4 is required for laboratory, radiology, and ultrasound interpretations by any provider other than the attending physician.
Laboratory tests that are generally considered part of a laboratory panel (e.g., chemistries, CBCs, urinalyses [UAs]) and that are performed on the same day must be billed as a panel regardless of the method used to perform the tests (automated or manual).
Physician interpretations that are requested of a consulting pathologist and require professional reading and reporting of results may be billed to Texas Medicaid 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.
Texas Medicaid follows the Medicare categorization of tests for CLIA certificate holders.
Refer to:
The CMS website at www.cms.gov/CLIA/10_Categorization_of_Tests.asp for information about procedure code and modifier QW requirements.
Subsection 2.2.5, “Automated Laboratory Tests and Laboratory Paneling,” in the Radiology and Laboratory Services Handbook (Vol. 2, Provider Handbooks) for claims processing instructions.
Subsection 2.1.1, “Clinical Laboratory Improvement Amendments (CLIA),” in the Radiology and Laboratory Services Handbook (Vol. 2, Provider Handbooks).
Subsection 3.4.2, “Reimbursement,” in the Radiology and Laboratory Services Handbook (Vol. 2, Provider Handbooks) for claims processing instructions.
Subsection 2.2, “Fee-for-Service Reimbursement Methodology,” in Section 2, “Texas Medicaid Fee-for-Service Reimbursement” (Vol. 1, General Information) for more information about reimbursement.

Texas Medicaid & Healthcare Partnership
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