Chapter

12

Laboratory Services

12.1 Enrollment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12-2 12.2 Clinical Laboratory Improvement Amendments (CLIA) of 1988 . . . . . . . . . . . . . . . . . 12-2 12.2.1 CLIA Requirements . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12-2 12.2.2 CLIA Regulations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12-2 12.2.2.1 Limits of Waiver and Physician Performed Microscopy Procedure (PPMP) CLIA Certificates . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12-2 12.2.2.2 Waiver Certificate . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12-3 12.2.2.3 Physician-Performed Microscopy Procedure (PPMP) Certificates. . . . . . . 12-3 12.3 Reimbursement . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12-3 12.3.1 2003 Clinical Laboratory Fee Schedule. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12-4 12.4 Benefits and Limitations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12-4 12.4.1 Hospital Laboratory Services . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12-4 12.4.2 Physician Laboratory Services . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12-4 12.4.3 Independent Laboratory Services . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12-4 12.4.4 Anatomical Pathology Services. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12-5 12.4.5 Cancer Screening . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12-5 12.4.6 Cytogenetics Testing for Leukemia and Lymphoma . . . . . . . . . . . . . . . . . . . . 12-5 12.4.7 Cytopathology of Vaginal, Cervical, and Uterine Sites. . . . . . . . . . . . . . . . . . . 12-6 12.4.8 Cytopathology Studies Other Than Vaginal, Cervical, or Uterine . . . . . . . . . . . 12-7 12.4.9 Helicobacter Pylori (H. Pylori) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12-7 12.4.10 Laboratory Panel Tests . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12-7 12.4.10.1 Chemistry Tests . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12-7 12.4.10.2 Complete Blood Counts (CBC) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12-8 12.4.10.3 Ferritin and Iron Studies. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12-8 12.4.11 Latex Sensitivity Testing . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12-9 12.4.12 Urinalysis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12-9 12.4.13 Repeated Procedures (Modifier 76 or 91) . . . . . . . . . . . . . . . . . . . . . . . . . . 12-9 12.4.13.1 Modifier 76 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12-9 12.4.13.2 Modifier 91 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12-10 12.4.14 Reference Labs and Lab Handling Fees . . . . . . . . . . . . . . . . . . . . . . . . . . 12-10 12.5 Claims Information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12-11

12

Chapter 12

12.1 Enrollment To enroll in the CSHCN Services Program, independent laboratories must be actively enrolled in the Texas Medicaid Program, have a valid Provider Agreement with the CSHCN Services Program, have completed the CSHCN Services Program enrollment process, and comply with all applicable state laws and requirements. An independent (freestanding) laboratory enrolled in the CSHCN Services Program is defined as a facility that meets the following criteria: • Facility independent from a physician’s office or hospital • Meets staff, equipment, and testing capability standards for certification by the Department of State Health Services (DSHS) • Medicare certified and enrolled as a Medicaid provider

12.2 Clinical Laboratory Improvement Amendments (CLIA) of 1988 12.2.1 CLIA Requirements To be eligible for reimbursement by the CSHCN Services Program, all providers performing laboratory tests must: • Enroll with the Centers for Medicare & Medicaid Services (CMS). • Receive a CLIA registration and/or certification number by contacting DSHS at 1-512-834-6650 or access CLIA information at www.dshs.state.tx.us/hfc/clia.htm. Submit CLIA applications to the following address: Department of State Health Services Health Facility Licensing and Compliance Division 1100 West 49th Street Austin, TX 78756 • Notify TMHP of the CLIA number at the following address: Texas Medicaid & Healthcare Partnership ATTN: Provider Enrollment PO Box 200795 Austin, TX 78720–0795

12.2.2 CLIA Regulations CMS, formerly the Health Care Financing Administration (HCFA), implemented CLIA, effective for dates of service on or after September 1, 1992. The CLIA regulations were published in the February 28, 1992, Federal Register and have been amended several times since. Copies of the CLIA rules and regulations are located at the CMS website at www.cms.hhs.gov. Important: TMHP-CSHCN monitors claims submitted by clinical laboratories for CLIA numbers. Claims submitted for laboratory services are denied if there is not a CLIA number on file with the CSHCN Services Program. These regulations concern all laboratory testing used for the assessment of human health or the diagnosis, prevention, or treatment of disease. CLIA regulations set standards designed to improve quality in all laboratory testing and included specifications for quality control (QC), quality assurance (QA), patient test management, personnel, and proficiency testing (PT). Under CLIA 88, all clinical laboratories (including those located in physicians offices), regardless of location, size, or type of laboratory must meet standards based on the complexity of the test(s) they perform.

12.2.2.1 Limits of Waiver and Physician Performed Microscopy Procedure (PPMP) CLIA Certificates CLIA certificates may limit the holder to performing only certain tests. Claims submitted to the CSHCN Services Program for laboratory services must accurately reflect those services authorized by CLIA and no other procedures. There are two types of certificates that limit holders to only certain test procedures: Waiver and Physician Performed Microscopy Procedure (CLIA-Certified) (PPMP) certificates.

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Laboratory Services

Providers are responsible for practicing within the limits of their certificates and maintaining awareness of the most current information regarding enforcement of CLIA provisions. A description of those test procedures follows.

12.2.2.2 Waiver Certificate Providers holding waiver CLIA certificates are authorized to perform only the following tests. The QW modifier is a CLIA requirement for these procedure codes (except as indicated below) and must be included or claims will be denied. Only the following selected waiver tests are a CSHCN benefit. Procedure Codes 80061QW

81002

81003QW

82010QW

82044QW

82055QW

82120QW

82270

82273QW

82274QW

82465QW

82523QW

82570QW

82679QW

82947QW

82950QW

82951QW

82952QW

82985QW

83001QW

83002QW

83026

83036QW

83518QW

83605QW

83718QW

83986QW

84443QW

84450QW

84460QW

84478QW

85013

85014QW

85018QW

85576QW

85610QW

85651

86294QW

86308QW

86318QW

86618QW

86701QW

86703QW

87077QW

87210QW

87449QW

87804QW

87807QW

87880QW

87899QW

G0107

12.2.2.3 Physician-Performed Microscopy Procedure (PPMP) Certificates Holders of PPMP certificates are authorized to perform all the procedures listed for waiver certificate in addition to the following tests: Procedure Codes 81000

81001

81015

81020

89190

Q0111

Q0112

Q0113

89055

12.3 Reimbursement In compliance with state laws, TMHP reimburses laboratories for most CSHCN services according to maximum fees established by federal law, Medicare, or DSHS. Clinical laboratory services are reimbursed at the lower of the national fee schedule or the billed amount. Some services (e.g., anatomical pathology) are reimbursed according to the Texas Medicaid Reimbursement Methodology (TMRM).

12

Effective for dates of service on or after September 1, 1999, the CSHCN Services Program pays only the amount allowed for the total component for the same procedure, same client, same date of service, and any provider. Providers who perform both the technical service and interpretation must bill for the total component. Providers who perform only the technical service must bill for the technical component. Providers who perform only the interpretation must bill for the interpretation component. Claims filed in excess of the amount allowed for the total component for the same procedure, same dates of service, same client, any provider, are denied. Claims are paid based on the order in which they are received. For example, if a claim is received for the total component, and TMHP has made payment for the technical and/or interpretation component for the same procedure, same dates of service, same client, any provider, the claim for the total component is denied as previously paid to another provider. The same is true if a total component is paid and subsequent claims are received for the individual components. As the result of the Tax Equity and Fiscal Responsibility Act (TEFRA) of 1982, independent laboratories are not directly reimbursed by the CSHCN Services Program when providing tests to clients registered as hospital inpatients or hospital outpatients. Reimbursement must be obtained from the hospital. These services cannot be billed to the client.

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12.3.1 2003 Clinical Laboratory Fee Schedule The Deficit Reduction Act (DEFRA) of 1984 requires clinical diagnostic laboratory tests that are performed in a physician's office by an independent laboratory or a hospital laboratory for its outpatients be reimbursed on the basis of maximum fee schedules. The Texas Medicare carrier publishes the fee schedules on an annual basis. By federal law, the CSHCN payment cannot exceed that allowed by Medicare.

12.4 Benefits and Limitations The CSHCN Services Program may reimburse the following laboratories for services when the laboratory is certified according to the CLIA regulations and enrolled in CSHCN: • A hospital laboratory for outpatient and non-patient clients • A physician’s office • An independent laboratory CLIA clinical laboratories must meet standards based on the complexity of the tests they perform regardless of location, size, or type of laboratory. To be reimbursed by the CSHCN Services Program, all providers performing laboratory tests must obtain the appropriate registration and/or certification. Laboratory tests generally performed as a panel and performed on the same day, by the same provider, must be billed as a panel, regardless of the method used to perform the test. Providers who forward a specimen to another laboratory may bill the appropriate handling fee (99000 or 99001) for collecting and forwarding the specimen to the other laboratory, if the specimen is collected by routine venipuncture or catheterization. Only one handling fee may be charged per day, per client, unless specimens are sent to two or more laboratories. If the specimen is divided and sent to multiple laboratories for testing, the referring laboratory/hospital must identify the performing laboratory's name and address or unique Texas Provider Identifier (TPI) number on the claim. Specific procedure or diagnosis codes related to program benefits and coverage may be listed in this chapter. These listings are intended to provide helpful information, but should not be considered allinclusive. From time to time, codes are added, deleted, or revised. Coverage and coding information is updated in the CSHCN Provider Bulletin. Call the TMHP-CSHCN Contact Center at 1-800-568-2413 with questions regarding covered procedure or diagnosis codes.

12.4.1 Hospital Laboratory Services Outpatient and nonpatient claims for laboratory services must reflect only tests actually performed by the hospital laboratory. However, hospital laboratories may bill for all of the tests performed on a specimen if some, but not all, of the tests are done by another laboratory on referral from the hospital submitting the claim.

12.4.2 Physician Laboratory Services The CSHCN Services Program reimburses laboratory services ordered by a physician and provided under the provider’s personal supervision in a setting other than an inpatient or outpatient hospital. If a physician performs more than 100 laboratory tests per year for other providers in their laboratory, the laboratory must be certified by CLIA, and the provider must enroll as an independent laboratory with TMHP. Physicians may only bill for those laboratory tests that are actually performed in their offices. A laboratory handling fee may be billed if the specimen is obtained by venipuncture or catheterization and sent to an outside laboratory. Only one lab handling fee per day, per client, may be billed, unless multiple specimens are obtained and sent to different laboratories. Interpretation of laboratory tests for the physician’s patients in the hospital, office, or emergency rooms are considered part of the physician’s professional services and should not be billed separately.

12.4.3 Independent Laboratory Services Independent laboratories that provide laboratory tests to clients registered as hospital inpatients or hospital outpatients are not directly reimbursed. Reimbursement must be obtained from the hospital.

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Laboratory Services

An independent laboratory that forwards a specimen to another laboratory without performing any tests on that specimen may not bill for laboratory tests. An independent laboratory may bill the CSHCN Services Program for tests referred to another laboratory (independent or hospital), only if the independent laboratory performs at least one test and forwards a portion of the same specimen to another laboratory to have one or more tests performed. In this instance, the referring laboratory may bill for tests it performs and all tests the reference laboratory performs on the specimen. In both instances, an independent laboratory that forwards a specimen to another laboratory may bill a handling fee for collection and forwarding the specimen, if the specimen is collected by venipuncture or catheterization.

12.4.4 Anatomical Pathology Services Clinical pathology services are not reimbursable services when furnished to inpatients and outpatients. A physician can bill for a clinical pathology consultation if the physician is personally involved in the clinical pathology procedure and all of the requirements listed below are met. To be considered for payment, clinical pathology consultation must: • Be requested by the patient’s attending physician. • Relate to a test result that lies outside the expected range in view of the condition of the patient. • Result in a narrative report included in the patient’s medical record that documents direct physician contact with the patient. • Require the exercises of medical judgment by the physician performing the consult.

12.4.5 Cancer Screening The following procedure codes are covered services: Procedure Codes 1-G0101

5/1-G0103

2-G0104

2-G0105

5-G0107

4/1/T-G0120

2-G0121

4/1/T-G0122

4/1/T-G0106

Additional information concerning cancer screening appears in Section 16.3.7, “Colorectal Cancer Screening,” on page 16-10. Information about cytopathology follows in Sections 12.4.7 and 12.4.8.

12.4.6 Cytogenetics Testing for Leukemia and Lymphoma Cytogenetics testing is a group of laboratory tests involving the study of chromosomes. This does not refer to genetic services. Clinical evidence supports the significance of cytogenetics evaluation in the diagnosis, prognosis, and treatment of acute leukemias and lymphomas, especially in children. The detection of the well-defined recurring genetic abnormalities often enables a correct diagnosis with important prognostic information affecting the treatment protocol.

12

Reimbursement for cytogenetics testing is limited to the following diagnosis codes: Diagnosis Code

Description

20280–20298

Other Lymphomas (malignant)

20400–20891

Leukemia

Cytogenetics testing is payable with the following procedure codes: • Tissue cultures: 5-88230, 5-88233, 5-88237, and 5-88239 • Cryopreservation and thawing: 5-88240 and 5-88241 • Chromosome analysis: 5-88245, 5-88248, 5-88249, 5-88261, 5-88262, 5-88263, 5-88264, 5-88280, 5-88283, 5-88285, and 5-88289 • Molecular cytogenetics: 5-88271, 5-88272, 5-88273, 5-88274, and 5-88275 • Interpretation and report: 5-88291

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The following information pertains to the cytogenetic testing procedure codes listed above: • Each provider may be paid one culture procedure (Tissue Culture section) and one chromosome analysis procedure (Chromosome Analysis section) for the same client on the same day. Each client will be limited to six culture procedures (Tissue Culture section) and six chromosome analysis procedures (Chromosome Analysis section) per 365 days. Each client will be limited to one cryopreservation and thawing procedure (Cryopreservation and Thawing section) and one molecular cytogenetics procedure (Molecular Cytogenetics section) per 365 days. • The procedures listed in the Tissue Cultures, Cryopreservation and Thawing, and Molecular Cytogenetics sections may be reimbursed when billed together for the same date of service. Only one procedure per section will be reimbursed and the others will be denied as part of. • Within the Chromosome Analysis section, only one procedure code can be reimbursed for each of the subcategories listed below. The other procedure codes will be denied as part of. •

Breakage syndromes: 88245, 88248, 88249 (when billed together, only one of these procedure codes will be reimbursed)

•

Cell counts: 88261 through 88264 (when billed together, only one of these procedure codes will be reimbursed)

•

Additional studies: 88280, 88283, 88285, and 88289 (when billed together, only one of these procedure codes will be reimbursed)

12.4.7 Cytopathology of Vaginal, Cervical, and Uterine Sites Because of the technical nature of processing and interpreting a Pap smear or specimen for cytopathology, pathologists are the only physician specialty reimbursed with the following exception: Exception: Other physician specialties equipped to perform Pap smears in their offices must have modifier PO on the claim form. Procurement and handling of the Pap smear or specimen for cytopathology is considered part of the evaluation and management of the client and is not reimbursed separately. A pathologist must report the place of service (POS) according to where the Pap smear is interpreted: POS 1 (office), POS 3 (inpatient), POS 5 (outpatient), or POS 6 (independent laboratory). Procedure codes 88141, 88142, 88143, 88147 through 88155, 88164 through 88167, 88174, and 88175 are reimbursed only to pathologists and CLIA-certified laboratories whose directors providing technical supervision of cytopathology services are pathologists. The following procedure codes are payable for gynecological cytopathology services: Procedure Codes 88141

88142

88143

88147

88148

88150

88152

88153

88154

88155

88164

88165

88166

88167

88174

88175 Procedure code 88155 is a benefit, but is not reimbursed when billed in addition to cyptopathology procedure codes 88142, 88143, 88147 through 88154, 88164 through 88167, 88174, and 88175. The interpretation portion of any gynecological cytopathology test must be reported using only procedure code 88141. Reimbursement is restricted to laboratories and pathologists. It is reimbursed in addition to cytopathology procedure codes 88142, 88143, 88147 through 88154, 88164 through 88167, 88174, and 88175. Procedure code 88141 is reimbursed only to a physician. It is denied when billed by a pathologist in conjunction with the total component for cytopathology procedures (procedure codes 88142 through 88143, 88147 through 88155, 88164 through 88167, 88174, and 88175). Procedure code 88155 is a benefit, but is not reimbursed when billed in addition to the cytopathology procedure codes 88142 through 88154, 88164 through 88167, 88174, and 88175.

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Laboratory Services

12.4.8 Cytopathology Studies Other Than Vaginal, Cervical, or Uterine Procurement and handling of the specimen is not reimbursed separately for cytopathology of sites other than vaginal, cervical, or uterine and will be considered part of the evaluation and management of the client. Procedure codes 88160 through 88162 may be reimbursed only to pathologists and CLIA-certified laboratories (whose directors providing technical supervision of cytopathology services are pathologists). These procedures are reimbursed according to the place of service where the cytopathology smear is interpreted. Procedures 5-88160, 5-88161, and 5-88162 are payable in the office (POS 1), outpatient setting (POS 5), or independent laboratory (POS 6). Procedures 1-88160, 1-88161, and 1-88162 are payable to a pathologist in the outpatient (POS 5) and inpatient hospital (POS 3) settings. Procedures 1/5-88160 or 1/5-88161 are denied as part of 1/5-88162. Procedure 1/5-88160 is denied as part of 5/I-88161. Reimbursement for procedure codes 88160 through 88162 is limited to pathologists (MD and DO) and laboratories (CLIA certified to provide pathology services).

12.4.9 Helicobacter Pylori (H. Pylori) Procedure codes 83013, 83014, 87338, and 87339 are a CSHCN benefit. These procedure codes are considered a clinical lab service and must be billed using type of service (TOS) 5. The interpretation/ professional component TOS I is not separately reimbursed. Procedure code 87338 is not payable on the same date of service to the same provider as procedure codes 83013 and/or 83014. If a gastrointestinal endoscopy (GED) is performed within 90 days of an H. Pylori test, procedure codes 2-43200, 2-43202, 2-43234, 2-43235, and 2-43239 are denied. These services may be appealed with submission of medical documentation that supports performance of the endoscopy. The following diagnosis codes are covered for procedure 87338: Diagnosis Codes 53100–53101

53110–53111

53120–53121

53130–53131

53140–53141

53150–53151

53160–53161

53170–53171

53190–53191

53200–53201

53220–53221

53230–53231

53240–53241

53250–53251

53260–53261

53270–53271

53290–53291

53400–53401

53410–53411

53420–53421

53430–53431

53440–53441

53450–53451

53460–53461

53470–53471

53490–53491

53500–53501

53510–53511

53550–53551

53560–53561

53680

78901–78902

78906 12

12.4.10 Laboratory Panel Tests Laboratory tests generally performed as a part of a laboratory panel and performed on the same day, by the same provider must be billed with the appropriate panel code.

12.4.10.1 Chemistry Tests Individual laboratory studies that are considered part of a specific panel are denied when billed on the same day as a related panel code and when billed by the same provider, unless modifiers 76 or 91 are used. The organ or disease panels that may be reimbursed by the CSHCN Services Program have distinct procedures codes that are further detailed in the table below and include the following: 80048, 80050, 80051, 80053, 80061, 80069, 80074, and 80076. Procedure Codes Basic Metabolic Panel (80048) 82310

82374

84295

84520

82435

82565

82947

84132

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Procedure Codes General Health Panel (80050) 80053 and 85025 or 85004 and 85027 or

85007 and 85027 or 85009 and 84443

Electrolyte Panel (80051) 82374

82435

84132

84295

Comprehensive Metabolic Panel (80053) 82040

82247

82310

82374

82435

82565

82947

84075

84132

84155

84295

84450

84460

84520

82565

82947

84155

84450

Lipid panel (80061) 82465

83718

84478

Renal Function Panel (80069) 82040

82310

82374

82435

84100

84132

84295

84520

86803

87340

82248

84075

Acute Hepatitis Panel (80074) 86705

86709

Hepatic Function Panel (80076) 82040

82247

84460

12.4.10.2 Complete Blood Counts (CBC) The procedure codes for complete blood counts (CBCs) and their components are listed below. Individual components billed the same date of service as a CBC procedure code are denied as part of another service. For blood counts use the appropriate Current Procedural Terminology (CPT) codes as follows: Procedure Codes 85004

85007

85008

85009

85013

85014

85018

85025

85027

85032

85041

85048

85049

Specialized blood counts procedures 85044, 85045, and 85046, may be reimbursed in addition to a CBC when performed on the same day.

12.4.10.3 Ferritin and Iron Studies The CSHCN Services Program may reimburse procedure codes 5-82728, 5-83540, 5-83550, 5-84466, and 5-85536 when billed with any of the following diagnosis codes: Diagnosis Codes 2750

2800

2801

2808

2809

2810

2811

2812

2819

28241–28249

28264

28268

2828

2829

2839

2850

28521

28522

28529

2859

5360

5728

5738

5739

5793

5798

5799

585

586

6482–64824

70900

V560

V5631

V5632

V568

If a ferritin and iron procedure are billed on the same day, procedure code 5-82728 is denied, and procedure code 5-83540 is paid. Procedure codes 5-82728 and 5-83540 are payable on the same day with the diagnosis codes 2750, Hemochromatosis; 28521, Anemia in ESRD; and/or 585, Chronic renal failure. 12–8

Laboratory Services

12.4.11 Latex Sensitivity Testing The CSHCN Services Program covers radioallergosorbent (RAST) testing for CSHCN clients when used to detect latex sensitivity. Use procedure code 86003 when billing for RAST testing. Requests for RAST testing are covered for the following diagnosis codes: Diagnosis Codes 5933

5934

5935

59370–59373

59382

5961

59800–5989

5991

6190–6198

6199

74100–74193

7522–75249

75261

75262

75263

7527

75320

75321

75322

75323

75329

7534

7535

7536

7537

7538 If the physician performs the test in the office, a modifier SU must be used, indicating that the necessary equipment to perform the test is in the office.

12.4.12 Urinalysis A similar methodology used with chemistry tests is applied when two or more components of a urinalysis are performed on the same day and billed separately. The billed services are also denied if not paneled appropriately and must be resubmitted with urinalysis codes 81000, 81001, 81002, or 81003. The following procedure codes are subject to this methodology: Procedure Codes 81000

81001

81002

81003

81015

81020

84578

84583

81005

If procedure codes 84578 and 84583 are billed on the same day as any of the above urinalysis procedure codes, procedure codes 84578 and 84583 will be denied as part of the urinalysis. Procedure code 81015 is denied as part of 81000 or 81001, if procedure code 81015 is billed in addition to routine urinalysis codes 81000 or 81001. If 81015 is billed with urinalysis codes 81002 or 81003, both procedure codes are denied requiring paneling into either 81000 or 81001. If 81015 is billed separately with one or more of the above components on the same day, both 81015 and the other component are denied and should be combined and billed as a urinalysis. Use procedure code 87086 when performing bacterial urine culture with antibiotic sensitivities. Procedure codes 82009, 82947, and 83986 are payable when billed on the same day as a urinalysis.

12.4.13 Repeated Procedures (Modifier 76 or 91) 12

12.4.13.1 Modifier 76 Modifier 76 is limited as follows: • Modifier 76 must not be used when billing the initial procedure. It must be used to indicate the repeated procedure. • If more than two services are billed on the same day by the same provider, regardless of the use of modifier 76, the claim or detail is denied. • If a repeated procedure performed by the same provider on the same day is billed without modifier 76, it is denied as a duplicate procedure. • If a claim is denied for a quantity more than two or as a duplicate procedure, the times of these procedures/services must be documented on appeal. • Modifier 76 is not required and must not be used when billing multiple quantities of a supply (e.g., disposable diapers or sterile saline). Certain procedure codes have been removed from modifier 76 auditing for dates of service on or after April 3, 1998. These procedure codes have been identified as routinely being performed at the same time, more than twice per day for each antigen (e.g., agglutinins, febrile [e.g., Brucella, Francisella,

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Chapter 12

Murine typhus, Q fever, Rocky Mountain spotted fever, scrub typhus], each antigen). Providers may still appeal claims that have been denied for documentation of time. Most procedure codes initially requiring modifier 76 will continue to be audited for modifier 76. When appealing claims with modifier 76 for repeat procedures, providers must separate the details. One detail should be appealed without the modifier and one detail with the modifier, including documentation of times for each repeated procedure.

12.4.13.2 Modifier 91 Effective for dates of service on or after May 5, 2004, modifier 91 should be used for repeat clinical diagnostic tests as follows: • Modifier 91 must not be used when billing the initial procedure. It must be used to indicate the repeated procedure. • If more than two services are billed on the same day by the same provider, regardless of the use of modifier 91, the claim or detail is denied. • If a repeated procedure performed by the same provider on the same day is billed without modifier 91, it is denied as a duplicate procedure. • If a claim is denied for a quantity more than two or as a duplicate procedure, the times of these procedures/services must be documented on appeal. • Modifier 91 is not required and must not be used when billing multiple quantities of a supply (for example, disposable diapers or sterile saline). Certain procedure codes have been removed from modifier 91 auditing. These are procedure codes that have been identified as routinely being performed at the same time, more than twice per day for each antigen (e.g., agglutinins, febrile [e.g., Brucella, Francisella, Murine typhus, Q fever, Rocky Mountain spotted fever, scrub typhus], each antigen). Providers may still appeal claims that have been denied for documentation of time. Most procedure codes initially requiring modifier 91 will continue to be audited for modifier 91. When appealing claims with modifier 91 for repeat procedures, providers must separate the details. One detail should be appealed without the modifier and one detail with the modifier, including documentation of times for each repeated procedure.

12.4.14 Reference Labs and Lab Handling Fees An independent laboratory may not bill for laboratory tests when the specimen is forwarded to another laboratory without performing any tests on that specimen. An independent laboratory may bill the CSHCN Services Program for tests referred to another laboratory (independent or hospital), only if the independent laboratory performs at least one test and forwards a portion of the same specimen to another laboratory (reference laboratory) to have one or more tests performed. In this instance, the referring laboratory may bill for tests it performs and all tests the reference laboratory performs on the specimen. When billing, the YES box in Block 20 of the CMS-1500 claim form must be marked, the name and TPI of the reference laboratory where the specimen was forwarded must be in Block 32, and the TPI of the reference laboratory must be indicated in Block 24K next to each procedure to be performed by the reference laboratory. Important: Only one handling fee may be charged per day, per client, unless specimens are sent to two or more laboratories. If the specimens are divided and sent to multiple laboratories for testing, the referring laboratory/hospital must identify the performing laboratory's name and address or unique TPI number on each claim. In both situations, an independent laboratory that forwards a specimen to another laboratory (independent or hospital) may bill a handling fee (99001) for collecting and forwarding the specimen to the other laboratory if the specimen is collected by venipuncture or catheterization. When billing for laboratory services, providers should use the date the specimen was collected as the date of service. If the specimen is sent to a reference laboratory and the client is an inpatient, the hospital is responsible for payment of these services to the reference laboratory.

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Laboratory Services

12.5 Claims Information Independent laboratory services must be submitted to TMHP-CSHCN in an appropriate electronic format or on a CMS-1500 claim form. Providers may purchase CMS-1500 claim forms from the vendor of their choice. TMHP does not supply the forms. See CMS-1500 Claim Form Instructions on page C-2 for more information on electronic claims submission. Blocks not referenced are not required for processing by TMHP and may be left blank.

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