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Chapter 22: Pathology and Laboratory Services


Billing & Payment Policies for Healthcare Services provided to Injured Workers and Crime Victims



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Effective July 1, 2012

Complete Chapter for printing

Look for possible updates and corrections to these payment policies

 

Table of contents

Definitions

Payment policies:
Bloodborne pathogens
Drug screens
Panel tests
Repeat tests
Specimen collection and handling
Stat lab fees

More info:
Related topics



 

Definitions

CPT® code modifier mentioned in this chapter:

–91

Repeat clinical diagnostic laboratory test

Performed on the same day to obtain subsequent report test value(s).  Modifier –91 must be used when repeat tests are performed on the same day, by the same provider to obtain reportable test values with separate specimens taken at different times, only when it is necessary to obtain multiple results in the course of treatment.  When billing for a repeat test, use modifier –91 with the appropriate procedure code.


Payment policy: Bloodborne pathogens

Prior authorization

The insurer may pay for post exposure treatment whenever an injury or probable exposure occurs and there is a potential exposure to an infectious disease.

Authorization of treatment in cases of probable exposure (not injury) doesn't bind the insurer to allowing a claim later.

The exposed worker must submit an accident report form before the insurer can pay for testing and treatment.

Services that can be billed

Diagnostic test or procedure
For diagnostic tests and procedures, the following CPT® codes can be billed:

  • 47100,
  • 83890,
  • 83894,
  • 83896,
  • 83898,
  • 83902,
  • 83912,
  • 86689,
  • 86701,
  • 86704,
  • 86706,
  • 86803-86804,
  • 87340,
  • 87390,
  • 87521-87522,
  • 87901, and
  • 87903-87904.

Testing related procedure

For testing related procedures, the following CPT® codes can be billed:

  • 78725,
  • 86360,
  • 87536,
  • 80076,
  • 90371,
  • 90746 (adult),
  • 90772-90779,
  • 99201-99215, and
  • 99217-99220.

Treating a reaction to testing or treatment of an exposure

The insurer will allow a claim and applicable accident fund benefits when a worker has a reaction to covered treatment for a probable exposure.

Covered test protocols

Testing schedule

Testing for hepatitis B, hepatitis C, and HIV should be done:

  • At the time of exposure, and
  • At 3, 6, and 12 months post exposure. 

Hepatitis B

For hepatitis B (HBV), the following test protocols are covered:

  • HbsAg (hepatitis B surface antigen),
  • Anti-HBc or HBc-Ab (antibody to hepatitis B core antigen), and
  • Anti-HBs or HBs-Ab (antibody to hepatitis B surface antigen).

Note: Treatment with hepatitis B immune globulin (HBIG) and the hepatitis B vaccine may be appropriate for post exposure prophylaxis.

Hepatitis C

For hepatitis B (HCV), the following test protocols are covered:

  • Enzyme Immunoassay (EIA),
  • Recombinant Immunoblot Assay (RIBA), and
  • Strip Immunoblot Assay (SIA).

Note: The qualitative reverse transcriptase polymerase chain reaction (RT-PCR) test is the only way to determine whether or not one has active HCV.

The following tests are covered services only if HCV is an accepted condition on the claim:

  • Quantitative reverse transcriptase polymerase chain reaction (RT-PCR),
  • Branched chain DNA (bDNA),
  • Genotyping, and
  • Liver biopsy.

HIV

For HIV, two blood tests are needed to verify the presence of HIV in blood:

  • Rapid HIV or EIA test, and
  • Western Blot test to confirm seropositive status.

The following tests are used to determine the presence of HIV in blood:

  • Rapid HIV test,
  • EIA test,
  • Western Blot test, and
  • Immunofluorescent antibody.

The following tests are covered services only if HIV is an accepted condition on the claim:

  • HIV antiretroviral drug resistance testing,
  • Blood count, kidney, and liver function tests,
  • CD4 count, and
  • Viral load testing.

Note: When a possible exposure to HIV occurs, the insurer will pay for chemoprophylaxis treatment in accordance with the most recent Public Health Services (PHS) Guidelines.  Prior authorization isn’t required.

When chemoprophylaxis is administered, the insurer will pay at baseline and periodically during drug treatment for drug toxicity monitoring including:

  • Complete blood count, and
  • Renal and hepatic chemical function tests.

Covered bloodborne pathogen treatment regimens

Chronic hepatitis B

For chronic hepatitis B (HBV):

  • Interferon alfa-2b, and
  • Lamivudine.

Hepatitis C

For hepatitis C (HCV) – acute:

  • Mono therapy, and
  • Combination therapy.

HIV/AIDS

For HIV/AIDS, covered services are limited to those within the most recent guidelines issued by the HIV/AIDS Treatment Information Service (ATIS).

Link: The ATIS guidelines are available on the web at http://aidsinfo.nih.gov/.


Payment policy: Drug screens

Services that can be billed

The insurer will pay for:

  • Drug screening conducted in the office setting by a laboratory with a Clinical Laboratory Improvement Amendment (CLIA) certificate of waiver, and
  • Confirmation testing performed at a laboratory not requiring a CLIA certificate of waiver.

Effective January 1, 2011, the department will pay for drug screening using the following CPT® and HCPCS codes:

  • 80100 (Drug screen, qualitative; multiple drug classes chromatographic method, each procedure),
  • 80102 (Drug confirmation, each procedure),
  • G0431 (Drug screen, qualitative; single drug class method – for example, immunoassay, enzyme assay – each drug class), and
  • G0434 (Drug screen, other than chromatographic; any number of drug classes, by CLIA waived test or moderate complexity test, per patient encounter).

Note: Also see “Payment limits” on these codes, below.

Payment limits

CPT® billing codes 80100, 80102 and G0431 are only payable to laboratories that don’t require a CLIA certificate of waiver.

HCPCS billing code G0434 is limited to one unit per day per patient encounter regardless of the CLIA status of the laboratory.

Services that aren’t covered

Effective January 1, 2011, the insurer doesn’t cover CPT® codes 80101 and 80104.

Payment policy: Panel tests

Services that can be billed

Automated multichannel tests

When billing for panels containing automated multichannel tests, performing providers may bill either the panel code or individual test codes, but not both.

The following tests (CPT® codes) are automated multichannel tests or panels comprised solely of automated multichannel tests:

  • 80048,
  • 80051,
  • 80053,
  • 80069,
  • 80076,
  • 82040,
  • 82247-82248,
  • 82310,
  • 82374,
  • 82435,
  • 82465,
  • 82550,
  • 82565,
  • 82947,
  • 82977,
  • 83615,
  • 84075,
  • 84100,
  • 84132,
  • 84155,
  • 84295,
  • 84450,
  • 84460,
  • 84478,
  • 84520, and
  • 84550.

Additional information: How to calculate payments

Automated tests

The automated individual and panel tests above are paid based on the total number of unduplicated automated multichannel tests performed per day per patient.

Calculate the payment using the following steps:

  • When a panel is performed, the CPT® codes for each test within the panel are determined, then
  • The CPT® codes for each test in the panel are compared to any individual tests billed separately for that day, then
  • Any duplicated tests are denied, then
  • The total number of remaining unduplicated automated tests is counted.

To determine the payable fee based on the total number of unduplicated automated tests performed, see the following table:

If the number of unduplicated automated tests performed is… Then the fee is:
1 test Lesser of the
single test or
$10.32.
2 tests $10.32
3-12 tests $12.67
13-16 tests $16.93
17-18 tests $18.96
19 tests $21.94
20 tests $22.62
21 tests $23.35
22-23 tests $24.07

 

Panels with automated and non-automated tests

When panels are comprised of both automated multichannel tests and individual nonautomated tests, they are priced based on the:

  • Automated multichannel test fee based on the number of tests, added to
  • Sum of the fee(s) for the individual non-automated test(s).

For example, CPT® code 80061 is comprised of 2 automated multichannel tests and 1 nonautomated test.  As shown in the table below, the fee for 80061 is $26.56.

If the CPT® 80061
component tests is:
And the number of
automated tests is…
Then the maximum
fee is:
Automated:
CPT® 82465 and
CPT® 84478
2 Automated:
$10.32
Non-automated:
CPT® 83718
n/a Non-automated:
$16.24
Maximum payment for CPT® code 80061:

$26.56

 

Multiple panels

When multiple panels are billed or when a panel and individual tests are billed for the same date of service for the same patient, payment will be limited to the total fee allowed for the unduplicated component tests.

The table below shows how to calculate the maximum payment when:

  • Panel codes 80050, 80061, and 80076 are billed with
  • Individual test codes 82977, 83615, 84439, and 85025.
Test type CPT® panel codes Individual tests Test count Max fee
80050 80061 80076
Automated tests 82040, 82247,
82310, 82374,
82435, 82565,
82947, 84075,
84132, 84155,
84295, 84450,
84460, and
84520
82465 and 84478 82248 + these
duplicated tests:
82040
,82247,
84075,84155,
84450,
and 84460
82977
83615
= 19 unduplicated
automated tests
(Note the fee in
previous table on
fees for automated
tests)
$21.94
  84443 $33.19
85025 or
85027 and
85004 or
85027 and
85007 or
85027 and
85009
$15.43
83718 $16.24
84439 $12.39
Non-automated tests 85025 or
85027 and
85004 or
85027 and
85007 or
85027 and
duplicated
test 85009
$0.00
Maximum payment: $99.19

Payment policy: Repeat tests

Requirements for billing

Additional payment is allowed for repeat test(s) performed for the same patient on the same day.  However, a specimen(s) must be taken from separate encounters.  Also, the medical necessity for repeating the test(s) must be documented in the patient’s record.

When billing, modifier –91 must be used to identify the repeated test(s).

Note: Payment for repeat panel tests or individual components tests will be made based on the methodology described in the “Panel Tests” payment policy section of this chapter (above).

Payment limits

Test(s) normally performed in a series (for example, glucose tolerance tests or repeat testing of abnormal results) don’t qualify as separate encounters.


Payment policy: Specimen collection and handling

Who must perform these services to qualify for payment

The fee for billed s pecimen collection services is payable only to the provider who actually draws the specimen.

Payment for the specimen may be made to nursing homes or skilled nursing facilities when an employee qualified to do specimen collection performs the draw.

Services that can be billed

Specimen collection

Complex vascular injection procedures, such as arterial punctures and venisections, aren’t subject to this policy and will be paid with the appropriate CPT® or HCPCS billing codes.

Travel

Travel will be paid in addition to the specimen collection fee when all of the following conditions are met:

  • It is medically necessary for a provider to draw a specimen from a nursing home, skilled nursing facility, or homebound patient, and
  • The provider personally draws the specimen, and
  • The trip is solely for collecting the specimen.

Note: Also see “Services that aren’t covered” and “Payment limits,” below.

Services that aren’t covered

Specimen collection
Specimen collection performed by patients in their homes isn’t paid (such as stool sample collection).

Travel
HCPCS code P9604 (Travel allowance, one way in connection with medically necessary laboratory specimen collection drawn from homebound or nursing homebound patient, prorated trip charge) isn’t covered.

Requirements for billing

Specimen collection

Use HCPCS billing codes:

  • P9612, which is for “Catheterization for collection of specimen, single patient, all places of service,” and
  • P9615, which is for “Catheterization for collection of specimen(s) multiple patient(s).”
  • For venipuncture, use CPT® billing code 36415.

Travel

To bill for actual mileage, use HCPCS code P9603 (1 unit equals 1 mile).

Note: Also see information about travel in “Services that can be billed,” above, and “Payment limits,” below.

Payment limits

Specimen collection

Costs for media, labor, and supplies (for example, gloves, slides, antiseptics, etc.) are included in the specimen collection.

Note: Payment for performing the test is separate from the specimen collection fee.

A collection fee isn’t allowed when the cost of collecting the specimen(s) is minimal, such as:

  • A throat culture,
  • Pap smear, or
  • A routine capillary puncture for clotting or bleeding time.

Handling

Handling and conveyance won’t be paid (for example, shipping, messenger, or courier service of specimen(s). This includes preparation and handling of specimen(s) for shipping to a reference laboratory. These are integral to the process and are bundled into the total fee for testing service.

Travel

Travel won’t be paid to nursing home or skilled nursing facility staff that performs specimen collection.

If the specimen draw is incidental to other services, no travel is payable.


 

Payment policy: Stat lab fees

Services that can be billed

Usual laboratory services are covered under the Professional Services Fee Schedule.

Link: The fee schedule is available on L&I’s website at http://feeschedules.Lni.wa.gov.

When lab tests are appropriately performed on a STAT basis, the provider may bill HCPCS codes S3600 or S3601.

Requirements for billing

Tests ordered STAT should be limited only to those needed to manage the patient in a true emergency situation.  Also:

  • The medical record must reflect the medical necessity and urgency of the service, and
  • The laboratory report should contain the name of the provider who ordered the STAT test(s).

Note: Payment is limited to one (1) STAT charge per episode (not once per test).

Payment limits

The STAT charge will only be paid with these tests:

  • HCPCS code G0306 (Complete CBC, auto w/diff),
  • HCPCS code G0307 (Complete CBC, auto),
  • HCPCS code G0431 (Drug screen, single class),
  • HCPCS code G0434 (Drug screen, multi drug class), or
… with these CPT® billing codes:
80047 80178 81001 82248 83615 84484 85032 86367 86971
80048 80184 81002 82310 83663 84512 85046 86403 87205
80051 80185 81003 82330 83874 84520 85049 86880 87210
80069 80188 81005 82374 83880 84550 85378 86900 87281
80076 80192 82003 82435 84100 84702 85380 86901 87327
80100 80194 82009 82550 84132 84704 85384 86902 87400
80156 80196 82040 82565 84155 85004 85396 86920 89051
80162 80197 82055 82803 84157 85007 85610 86921  
80164 80198 82150 82945 84295 85025 85730 86922
80170 81000 82247 82947 84450 85027 86308 86923


 

If you’re looking for more information about… Then go here:
Administrative rules
for billing procedures
Washington Administrative Code (WAC) 296-20-125:
http://app.leg.wa.gov/wac/default.aspx?cite=296-20-125
AIDS Treatment Intervention
Service (ATIS) guidelines
National Institute of Health (NIH) website:
http://aidsinfo.nih.gov/
Becoming an L&I provider L&I’s website:
www.Lni.wa.gov/ClaimsIns/Providers/Becoming/default.asp
Billing instructions and forms Chapter 2:
Information for All Providers
Fee schedules for all healthcare
services (including pathology and
laboratory services)
L&I’s website:
http://feeschedules.Lni.wa.gov

Need more help?  Call L&I’s Provider Hotline at 1-800-848-0811.


CPT® codes and descriptions only are © 2011 American Medical Association

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