(1)
Covered Billing Situations. Except as provided in
101
CMR 320.03(2), the method of
determining rates of payment contained in 101 CMR 320.00 apply to clinical
laboratory services provided to publicly aided individuals, with the following
conditions.
(a) If clinical laboratory
services are performed by an independent clinical laboratory, then the
independent clinical laboratory must bill the governmental unit directly. The
independent clinical laboratory may not bill indirectly by having a physician
or dentist bill either the payer or the patient for services performed by the
independent clinical laboratory.
(b) If clinical laboratory services are
performed by a registered physician or dentist, or by an agent under his or her
direct supervision, in his or her private medical office or clinic, then the
registered physician or dentist must bill the governmental unit
directly.
(2)
Excluded Billing Situations. 101 CMR 320.00 and the
rates of payment contained in 101 CMR 320.00 do not govern the rates of payment
for clinical laboratory services if
(a) the
service is provided in state institutions by a state-employed physician,
dentist, or dentist consultant;
(b)
the service is provided by a physician or dentist whose salary from a hospital
or affiliated medical school includes compensation for professional services
rendered to patients; or
(c) the
physician, dentist, or independent laboratory does not customarily bill private
patients without health insurance under comparable circumstances.
(3)
Professional and
Technical Component Services. Some laboratory services have both
professional and technical components. The professional component is set forth
in 101 CMR 316.00: Rates for Surgery and Anesthesia Services,
while the technical component is set forth in 101 CMR 320.00.
(a) The relevant codes for laboratory
services containing both professional and technical components are 83020,
84165, 84166, 84181, 84182, 85390, 85576, 86255, 86256, 86320, 86325,86327,
86334, 86335, 87164, 87207, and 89060.
(b) Surgical pathology services are excluded
from 101 CMR 320.00 and instead included in 101 CMR 316.00: Rates for
Surgery and Anesthesia Services. Surgical pathology services include
codes 80503, 80504, 80505, 80506, 85060, 85097, 85396, 86077, 86078, 86079,
86153, 86486, 86490, 86510, 86580, 88104, 88106, 88108, 88112, 88120, 88121,
88125, 88141, 88160, 88161, 88162, 88172, 88173, 88177, 88182, 88184, 88185,
88187, 88188, 88189, 88199, 88291, 88299, 88300, 88302, 88304, 88305, 88307,
88309, 88311, 88312, 88313, 88314, 88319, 88321, 88323, 88325, 88329, 88331,
88332, 88333, 88334, 88341, 88344, 88346,
88348,88350,88355,88356,88358,88360,88361, 88362, 88363, 88365, 88366, 88367,
88368, 88369, 88374, 88375, 88377, 88380, 88381, 88387, 88388, 88399, 89049,
89060, 89220, 89230, and 89240.
