Date: February 13, 2018
To: Enrolled Hospitals: Chief Executive Officers, Chief Financial Officers, and Patient Accounts Managers; and Independent Laboratories
Re: Use of Modifier 90 [Reference (Outside) Laboratory] for Hospital Fee-for-Service Outpatient Claims Billed on the 837P or HFS 2360 Claim Formats Effective March 1, 2018
This notice details a new billing requirement for hospitals billing fee-for-service for lab services performed at a reference laboratory.
Current Department policy states that if a reference laboratory has a financial agreement with a hospital to provide services for a hospital, then the hospital is entitled to bill the Department for both the professional and technical components of the service rendered at the lab for outpatient services. The hospital cannot bill for laboratory services done by a reference laboratory during an inpatient stay or when there is a billable Ambulatory Procedures Listing (APL) service.
Effective with dates of service on and after March 1, 2018, hospitals will be required to identify outpatient lab services performed at a reference laboratory by utilizing modifier 90 - Reference (Outside) Laboratory in conjunction with the procedure code. This will allow the Department to track services performed at a reference lab and prevent potential duplication of payment.
Reference laboratories contracting with hospitals to perform lab services must be enrolled with the Department. HFS is obligated by federal law to verify that providers rendering services to Medical Assistance participants are licensed/certified as applicable. Refer to the IMPACT enrollment webpage for more information.
If a reference laboratory is not utilized, hospitals are limited to billing the technical component only of an ordered lab service. The professional component must be billed under the name and NPI of the pathologist.
Questions regarding this notice may be directed to the Bureau of Professional and Ancillary Services at 1-877-782-5565.
Felicia F. Norwood