Date: July 20, 2018
To: Participating Independent Laboratories; Hospitals; and Physicians
Re: Chapter L-200, Handbook for Providers of Laboratory Services
Correction Regarding Global Laboratory Billing in the Hospital Outpatient Setting and Hospital Use of Modifier “90” for Reference Laboratory Services
This bulletin corrects information contained in Topic L-210.1.2 regarding HFS 2360 billing for laboratory services.
In the hospital outpatient setting, the professional component of laboratory services must be billed under the name and NPI of the physician who performed the service, whether or not that physician is salaried. The hospital may not bill the global service. Hospitals may only bill the global service for lab tests performed in a reference laboratory and must identify those reference lab services using modifier “90”.
Topic L-210.1.2 has been revised to reflect the accurate billing instructions.
Topic L-210.1.2 HFS 2360 Claim form
Remove pages HFS L-210 (1-2) and insert new pages HFS L-210 (1-2) revised June 2018
L-210 General Limitations and Considerations on Covered Services
L-210.1 Technical and Professional Components
For any given lab test, no more than one provider may be reimbursed for the technical component of a service and no more than one provider may be reimbursed for the professional component.
Practitioners billing the technical component only must use modifier “TC”. Practitioners billing the professional component only must use modifier “26”. Both technical and professional components are implied when no modifier is entered.
L-210.1.1 HFS 2211 Claim Form
Payment to an independent laboratory includes both the technical and professional components. Payment will not be made to a practitioner for the interpretation of any tests performed and billed by an independent laboratory.
Independent laboratories may not bill the Department for lab tests done during an inpatient stay. The all-inclusive rate that the hospital receives is considered to cover all services provided during the inpatient stay.
L-210.1.2 HFS 2360 Claim Form
Revised June 2018
A practitioner may charge for tests performed in the practitioner’s office by the practitioner’s staff. Payment made by the Department for laboratory tests performed in the practitioner’s office includes both the professional and technical component fees. A practitioner may not charge for laboratory tests when a specimen is obtained but sent out of the office, e.g., skin lesions, pap smears, etc.
A central laboratory, serving practitioners in group practice is considered a practitioner’s office laboratory.
For laboratory services in the hospital outpatient setting, hospitals may bill for the technical component when the hospital obtains the specimen and completes the test. The claim for the professional services of the pathologist, whether the pathologist is salaried by the hospital or not, must be submitted under the name and NPI of the pathologist.
Hospitals frequently utilize reference laboratories (an off-site laboratory that completes the procedure on the specimen provided to them). 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. If no such financial agreement exists, the laboratory may submit charges to the Department.
Hospitals must utilize modifier “90” when billing to designate outpatient lab services that were performed by a reference laboratory. Hospitals cannot bill for laboratory services done by a reference laboratory during an inpatient stay or when there is a billable APL service.
The Department will only pay an individual service one time. If both the hospital and the reference laboratory bill the same service, the claim received first by the Department will pay.
L-210.2 Multiples of the Same Test on the Same Day
L-210.2.1 Independent Laboratories
In order for an independent laboratory to bill for multiples of the same test performed on the same date of service, the laboratory must use both the CPT code for the test being performed and the appropriate unlisted code. The CPT code for the test being performed is placed in the procedure code portion of the service section for test #1 and the name of the test or a description is placed in the procedure description field. The charge for the first test is placed in the provider charge field. The appropriate unlisted procedure (example 87999) is placed in the procedure code field of the next service section. The name(s) and number of the additional test(s) must be shown in the procedure description field and one charge, which includes all the additional tests billed under the unlisted code, is to be entered in the charge field. If there is not adequate space on the billing form to describe the additional service(s), either a narrative description of the test(s) or test results must be attached to the claim.
L-210.2.2 Hematology Tests for All Other Providers
A practitioner may bill for multiples of hematology services by using the days/unit field. When multiples of a hematology service are performed, the practitioner enters a 4 digit code in the days/unit field (example: 0004 for 4 tests within a 24 hour time period). If a quantity greater than 5 is placed in the Days/Units field, either the test results or a narrative explanation of the services must be attached to the claim.
A hospital billing fee for service for multiple hematology services is to use the same procedure as that described for a practitioner.
L-210.2.3 Pathology Services for All Other Providers
A practitioner may bill for multiples of pathology services by using the Days/Units field. When multiples of a pathology service are performed, the practitioner enters a 4 digit code in the Days/Units field (example: 0004 for 4 tests within a 24 hour time period). If a quantity greater than 5 is placed in the Days/Units field, either the test results or a narrative explanation of the services must be attached to the claim.