General
Chapter 1
Section 13
Laboratory Services
Issue Date: August 26, 1985
Copyright: CPT
only © 2006 American Medical Association (or such other date of
publication of CPT).
All Rights Reserved.
Revision:
1.0 APPLICABILITY
This policy is mandatory for reimbursement
of services provided by either network or non-network providers.
However, alternative network reimbursement methodologies are permitted
when approved by the Defense Health Agency (DHA) and specifically
included in the network provider agreement.
2.0 ISSUE
How are laboratory services to be reimbursed?
3.0 POLICY
3.1 For purposes
of the instructions that follow, a diagnostic laboratory test, whether
performed in a physician’s office, in an independent laboratory,
or in another laboratory, is to be treated by the contractor as
a laboratory service. The term “another laboratory”, refers to such
examples as a reference laboratory that performs services only for
other laboratories, or a hospital laboratory functioning as an independent
laboratory. Also, when physicians and approved laboratories perform
the same test, whether manually or with automated equipment, the
services will be deemed similar and the respective charges of all
physicians and approved laboratories for that test must be commingled
in the computation of the prevailing charge in the state for the
test.
3.2 Determining Prevailing Charges for Single Laboratory
Tests.
3.2.1 No distinction should generally be made in
determining allowable charges for laboratory services between (a)
the sites where the service is performed, i.e., physicians’ offices
or other laboratories; or (b) the methods of the testing process
used, whether manual or automated.
3.2.2 Therefore, when only one test
is performed for a patient, the prevailing charge for the single
laboratory test shall be derived from the charges (weighted by frequency)
of both the physicians and other laboratories that perform the test
in the state, including tests performed manually or with automated
equipment. The automated equipment charges to be used are those
for a single test that is not performed as part of a battery of
tests. The charges of physicians include charges for tests performed
in their own offices as well as charges billed for tests performed
by other laboratories. The charges of other laboratories include
only those charges billed to the general public but not to physicians.
3.3 Refer to
Chapter 15, Section 1 for reimbursement requirements
for laboratory services provided by a Critical Access Hospital (CAH).
4.0 Exception
Effective October 1, 2008, Current Procedural
Terminology (CPT) procedure codes 81000 through 81003 (urinalysis),
shall be separately reimbursed when billed with an Evaluation and Management
(E/M) CPT code, rather than subject to any claims auditing software
edit. Payment is the lesser of the billed charge, the negotiated
rate, or the CHAMPUS Maximum Allowable Charge (CMAC).
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