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.
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).