Code of Massachusetts Regulations
101 CMR - EXECUTIVE OFFICE FOR HEALTH AND HUMAN SERVICES
Title 101 CMR 320.00 - Rates for Clinical Laboratory Services
Section 320.04 - General Rate Provisions and Maximum Fees

Universal Citation: 101 MA Code of Regs 101.320

Current through Register 1531, September 27, 2024

(1) Rate Determination. Payment rates are the lowest of

(a) the eligible provider's usual and customary charge to patients other than publicly aided individuals or industrial accident patients;

(b) the applicable listing from the schedule of allowable fees listed in 101 CMR 320.05; or

(c) the amount that is allowable under 42 U.S.C. § 1396b(i)(7).

(2) Individual Consideration (I.C.). Unlisted procedures and laboratory tests designated I.C. are individually considered items. The eligible provider's bill for such a test must be accompanied by a brief report of the procedure or test performed and the eligible provider's usual and customary charge for that procedure or test. Determination of appropriate payments for procedures and tests designated I.C. are in accordance with the following standards and criteria:

(a) time required to perform the procedure;

(b) degree of skill required in the procedure performed;

(c) severity or complexity of the patient's disease, disorder, or disability;

(d) policies, procedures, and practices of other third-party purchasers of care;

(e) prevailing medical-laboratory ethics and accepted custom of the medical-laboratory community; and

(f) such other standards and criteria as may be adopted by EOHHS. In no event may an eligible provider bill or be paid in excess of the usual and customary charge for the service.

(3) Administrative and Supervisory Duties. The rates of payment under 101 CMR 320.00 are full compensation for clinical laboratory services rendered to publicly aided individuals, as well as any related administrative or supervisory duties in connection with clinical laboratory services, without regard to where the service is rendered.

(4) Profile (or Panel) Tests. In no event may an eligible provider bill or be paid separately for each of the tests included within a profile test when a profile test has either been performed by the provider or requested by an authorized person.

(5) Limitations on Payment for Panel Tests.

(a) Any combination of the following tests when performed on a single patient on a single date of service is regarded as a single panel test:

80047

Basic Metabolic Panel -calcium, ionized (Consists of 82330, 82374, 82435, 82565, 82947, 84132, 84295, 84520): eight individual tests

80048

Basic Metabolic Panel -calcium, total (Consists of 82310, 82374, 82435, 82565, 82947, 84132, 84295, 84520): eight individual tests

80051

Electrolyte Panel (Consists of 82374, 82435, 84132, 84295): four individual tests

80053

Comprehensive Metabolic Panel (Consists of 82040, 82247, 82310, 82374, 82435, 82565, 82947, 84075, 84132, 84155, 84295, 84460, 84450, 84520): 14 individual tests

80061

Lipid Panel (Consists of 82465, 83718, 84478): three individual tests

80069

Renal Function Panel (Consists of 82040, 82310, 82374, 82435, 82565, 82947, 84100, 84132, 84295, 84520): ten individual tests

80076

Hepatic Function Panel (Consists of 82040, 82247, 82248, 84075, 84155, 84460, 84450): seven individual tests

82040

Albumin; serum

82247

Bilirubin; total

82248

Bilirubin; direct

82310

Calcium; total

82374

Carbon dioxide (bicarbonate)

82435

Chloride; blood

82465

Cholesterol, serum or whole blood, total

82550

Creatine kinase (CK), (CPK); total

82565

Creatinine; blood

82947

Glucose; quantitative

82977

Glutamyltransferase, gamma (GGT)

83615

Lactate dehydrogenase (LD), (LDH)

84075

Phosphatase, alkaline

84100

Phosphorus, inorganic (phosphate)

84132

Potassium; serum, plasma or whole blood

84155

Protein; total, except refractometry

84295

Sodium; serum, plasma or whole blood

84450

Transferase; aspatrate amino (AST), (SGOT)

84460

Transferase; alanine amino (ALT), (SGPT)

84478

Triglycerides

84520

Urea nitrogen; quantitative

84550

Uric acid; blood

(b) Panel tests are reimbursed according to the following schedule.

Code

Rate

Description

ATP02

$5.60

Auto Test Panel Pricing Code, 1-2 Tests

ATP03

$7.14

Auto Test Panel Pricing Code, 3 Tests

ATP04

$7.54

Auto Test Panel Pricing Code, 4 Tests

ATP05

$8.39

Auto Test Panel Pricing Code, 5 Tests

ATP06

$8.41

Auto Test Panel Pricing Code, 6 Tests

ATP07

$8.78

Auto Test Panel Pricing Code, 7 Tests

ATP08

$9.09

Auto Test Panel Pricing Code, 8 Tests

ATP09

$9.34

Auto Test Panel Pricing Code, 9 Tests

ATP10

$9.34

Auto Test Panel Pricing Code, 10 Tests

ATP11

$9.49

Auto Test Panel Pricing Code, 11 Tests

ATP12

$9.69

Auto Test Panel Pricing Code, 12 Tests

ATP13

$11.34

Auto Test Panel Pricing Code, 13 Tests

ATP14

$11.34

Auto Test Panel Pricing Code, 14 Tests

ATP15

$11.34

Auto Test Panel Pricing Code, 15 Tests

ATP16

$11.34

Auto Test Panel Pricing Code, 16 Tests

ATP17

$11.42

Auto Test Panel Pricing Code, 17 Tests

ATP18

$11.42

Auto Test Panel Pricing Code, 18 Tests

ATP19

$11.89

Auto Test Panel Pricing Code, 19 Tests

ATP20

$12.28

Auto Test Panel Pricing Code, 20 Tests

ATP21

$12.66

Auto Test Panel Pricing Code, 21 Tests

ATP22

$13.04

Auto Test Panel Pricing Code, 22 Tests

ATP23

$13.04

Auto Test Panel Pricing Code, 23 or more Tests

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