Current through Vol. 42, No. 1, September 16, 2024
This Part covers the guidelines for payment of laboratory
services by a provider in his/her office, a certified hospital or independent
laboratory, and for a pathologist's interpretation of laboratory
procedures.
(1)
Physician and
clinic provider laboratories. Physician and clinic providers may be
reimbursed for compensable clinical diagnostic laboratory services only when
they personally perform or supervise the performance of the test. If a
physician or clinic provider refers specimen to a certified laboratory or a
hospital laboratory serving outpatients, the certified laboratory or the
hospital must bill for performing the test.
(2)
Independent and hospital
laboratories. Independent and hospital laboratories will be required to
submit a letter to OHCA Provider Enrollment along with their other required
contracting documents. The reference laboratory must be identified on the claim
as well as the following information for any and all reference laboratories:
(A) Name;
(B) Address; and
(C) Clinical Laboratory Improvement Amendment
of 1988 (CLIA) ID.
(3)
Compensable services for independent, physician and hospital
laboratories.
(A) Reimbursement for
lab services is made in accordance with CLIA. These regulations provide that
payment may be made only for services furnished by a laboratory that meets CLIA
conditions, including those furnished in physicians' offices. Regulations
specify that any and every facility which tests human specimens for the purpose
of providing information for the diagnosis, prevention, or treatment of any
disease, or impairment of, or the assessment of the health of human beings is
subject to CLIA. All facilities which perform these tasks must make application
for certification by CMS. Eligible SoonerCare providers must be certified under
the CLIA program and have obtained a CLIA ID number from CMS and have a current
contract on file with the OHCA. Providers performing laboratory services must
have the appropriate CLIA certification specific to the level of testing
performed.
(B) Only medically
necessary laboratory services are compensable.
(i) Testing must be medically indicated as
evidenced by member-specific indications in the medical record.
(ii) Testing is only compensable if the
results will affect member care and are performed to diagnose conditions and
illnesses with specific symptoms.
(iii) Testing is only compensable if the
services are performed in furtherance of the diagnosis and/or treatment of
conditions that are covered under SoonerCare.
(C) Laboratory testing must be ordered by the
physician or non-physician provider and must be individualized to the member
and the member's medical history, or assessment indicators as evidenced in the
medical documentation.
(D)
Laboratory testing for routine diagnostic or screening tests following clinical
guidelines such as those found in the American Academy of Pediatrics (AAP)
Bright Futures' periodicity schedule, the United States Preventive Services
Task Force (USPSTF) A and B recommendations, the American Academy of Family
Practitioners (AAFP), or other nationally recognized medical professional
academy or society standards of care, is compensable. Additionally, such
sources as named in this subdivision should meet medical necessity criteria as
outlined in Oklahoma Administrative Code (OAC)
317:30-3-1(f).
(4)
Non-compensable
laboratory services.
(A) Laboratory
testing for routine diagnostic or screening tests not supported by the clinical
guidelines of a nationally recognized medical professional academy or society
standard of care, and/or testing that is performed without apparent
relationship to treatment or diagnosis of a specific illness, symptom,
complaint or injury is not covered.
(B) Non-specific, blanket panel or standing
orders for laboratory testing or lab panels which have no impact on the
member's plan of care are not covered.
(C) Split billing or dividing the billed
services for the same member for the same date of service by the same rendering
laboratory into two (2) or more claims is not allowed.
(D) Separate payment is not made for blood
specimens obtained by venipuncture or urine specimens collected by a provider
who is also performing the laboratory testing as these services are considered
part of the laboratory analysis.
(E) Claims for inpatient full-service
laboratory procedures are not covered since this is considered a part of the
hospital rate.
(F) Billing multiple
units of nucleic acid detection for individual infectious organisms when
testing for more than one (1) infectious organism in a specimen is not
permissible. Instead, OHCA considers it appropriate to bill a single unit of a
procedure code indicated for multiple organism testing.
(G) Billing multiple Current Procedural
Terminology (CPT) codes or units for molecular pathology tests that examine
multiple genes or incorporate multiple types of genetic analysis in a single
run or report is not permissible. Instead, OHCA considers it appropriate to
bill a single CPT code for such test. If an appropriate code does not exist,
then one (1) unit for an unlisted molecular pathology procedure may be
billed.
(5)
Covered
services by a pathologist.
(A) A
pathologist may be paid for the interpretation of inpatient surgical pathology
specimen when the appropriate CPT procedure code and modifier is
used.
(B) Full service or
interpretation of surgical pathology for outpatient surgery performed in an
outpatient hospital or ambulatory surgery center setting.
(6)
Non-compensable services by a
pathologist. The following are non-compensable pathologist services:
(A) Experimental or investigational
procedures. For more information regarding experimental or investigational
including clinical trials, see OAC
317:30-3-57.1.
(B) Interpretation of clinical laboratory
procedures.
Added at 12 Ok Reg
751, eff 1-5-95 through 7-14-95 (emergency); Added at 12 Ok Reg 3131, eff
7-27-95; Amended at 27 Ok Reg 704, eff 2-4-10 (emergency); Amended at 27 Ok Reg
1450, eff 6-11-10
