Written by Marilyn Glidden, CPC, CPMA, CGSC, CGIC
Clinical laboratory test billing and payment. Beginning in Calendar Year 2014, payment for most laboratory tests, except for molecular pathology tests, will be packaged under the OPPS. The general rule for OPPS Hospital is laboratory test should be reported on a 13X type of bill.
Now, there are limited circumstances when hospitals can separately bill the laboratory tests. For these specific situations, CMS is expanding the use of the 14X type of bill to allow separate billing and payment at clinical laboratory fee schedule rates for hospital outpatient laboratory test and the laboratory test that may be billed on the 14X claim and follow these circumstances.
Number one, it is a non-patient laboratory specimen test; and non-patient status continues to be defined as a beneficiary is neither an inpatient nor an outpatient, but a specimen has been submitted for analysis to a lab.
Number two, when hospitals only provide laboratory test to the patient directly, or under arrangement, and the patient does not also receive other hospital services during that same encounter. And finally three, when the hospital provides the laboratory test during the same encounter as other hospital services that is clinically unrelated to those hospital services and the laboratory test is ordered by a different practitioner than the practitioner who ordered the other hospital outpatient services provided to the hospital outpatient - provided in the hospital outpatient setting. In this case, the lab test could be billed on a 14X type of bill and the other hospital outpatient services would be billed on a 13X claim.
References for Laboratory testing-
http://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/Downloads/R2845CP.pdf
http://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/Downloads/R2971CP.pdf