Reimbursements

Category:

Lab Services: General Guidelines

Reimbursement Policy: NDRP-LP-001
Topic: Lab and Pathology
Effective Date: July 1, 2018
Last Reviewed:
February 25, 2019

Description:

The following policy addresses Blue Cross and Blue Shield of North Dakota’s (Blue Cross) general guides for lab services, and related services such as visits in addition to lab tests, “standing orders”, purchased outside lab, stat lab charges, repeat lab, and Blue Card lab billing.

Definitions:

A medical or clinical laboratory is a facility equipped to perform tests on specimens obtained from a patient in order to diagnose, treat or prevent an illness. Specimens include but are not limited to blood, other body fluids, tissue specimens and organs. A variety of tests are available that pertain to chemistries, microbiology, hematology and genetics as well as anatomic pathology that includes macroscopic or gross pathology of specimens and organs as well as microscopic pathology that encompasses cytology, histology and electron microscopy of tissue samples.

Laboratory and pathology procedures should be submitted using the CPT or HCPCS code(s) that best describe the service(s).  CPT Codes 80047-89398 encompass the majority of laboratory and pathology procedures.

Policy:

Blue Cross does not allow providers to bill the health plan for laboratory services that are not ordered by a physician or other qualified practitioner because, in addition to receiving lab results, the patient also needs interpretation of the tests, recommendations for future care, and a course of action that only a physician or other qualified practitioner can deliver. In addition, tests must be medically necessary in order to be eligible for coverage.

As a result, we will only issue payment for services that are coordinated by a physician or other qualified practitioner. A qualified practitioner is a practitioner recognized as an eligible provider by Blue Cross and practices within the scope of his or her licensure. Specific licensing questions should be directed to your specialty’s licensing board.

The services listed in the pathology and laboratory section of the CPT manual may be provided by the pathologist or alternatively by technologists who are under the supervision of the pathologist or practitioner.

The guidelines outlined below should be adhered to when submitting laboratory services to Blue Cross.

Office Visits

A level-of-service office visit (such as 99201-99215) may be submitted in addition to laboratory tests only when additional separately identifiable services are provided.

Organ or Disease-Oriented Panels

The tests listed under each panel (80047-80076) identify the defined components of that panel, and all tests listed must be performed in order to bill for that panel. Tests performed in addition to those specifically indicated for a particular panel can be billed separately in addition to the panel code.

Lab panels should be reported as one (1) line item, with one (1) unit per panel.

Standing Orders

Generally, laboratory tests performed because of standing orders on file for certain patients are not covered. One example of this is a standing order for routine screening tests when the patient has no clinical symptoms or is not taking medications. Laboratory services based on standing orders are covered only if you can show the medical necessity of the services through your medical records or if the patient has routine screening benefits and the tests are coded with an ICD-10-CM as routine services.

Purchased Services/Outside Lab

The entity that performs a test should be the one to bill for that test. However, a provider may, under arrangement with another provider, bill a service that is purchased from that other provider. For example, a clinic may bill for a Pap smear that is sent to an independent lab for analysis. It is important to remember that only one provider may bill for the service.

Stat Lab Charges

Charges for stat laboratory requests (S3600 and S3601) are not allowed. If submitted, they will deny as provider liability.

Repeat Lab Services

Repeat services require modifier -91 (not -59), unless the narrative supports submission of multiple units. The medical necessity for the repeat service must be documented in the patient’s record.

Lab Billed through the BlueCard® Program

Blue plans* may contract with providers outside of their exclusive service area for services provided to local and BlueCard members within their own service area for independent clinical lab services. Blue plans may not contract for such services for their members who receive services outside of their service area.

Providers who perform lab services should file the claim to the Blue plan where the referring physician is located. The claim will be reimbursed based on provider’s participation status with that Blue plan.

* Each local Blue Cross and/or Blue Shield plan is an independent licensee of the Blue Cross and Blue Shield Association