(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:
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.
