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 The contractor
shall treat, 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, 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:
3.2.1.1 The sites where the service
is performed, e.g., physicians’ offices or other laboratories; or
3.2.1.2 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) 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).