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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