(Medicare Claims Processing Manual)

 The test was performed following a hospital outpatients discharge from the        hospital  outpatient department;    The specimen was collected from a hospital outpatient during an encounter                      (as both are defined in 42 CFR  410.2);    It was medically appropriate to have collected the sample from the hospital outpatient during the hospital outpatient encounter;    The results of the test do not guide treatment provided during the hospital outpatient  encounter; and   The test was reasonable and medically necessary for the treatment of an  illness.   For the purpose of section 40.8.C, a  blood bank or center means an entity whose primary function is the performance or responsibility for the performance of, the collection, processing, testing, storage and/or distribution of blood or blood components intended for transfusion and transplantation.    50 - A/B MAC (B)  Claims Processing  (Rev. 1, 10- 01-03)  50.1 - Referring Laboratories  (Rev. 85, 02- 06-04) B3-5114.1  Medicare recognizes that specimens drawn or collected by one laboratory are sometimes referred to another laboratory for testing.  Payment for a Medicare -covered, referred laboratory service may be made under the rules established in Chapter 15 40.1.  The rules specified Chapter 15 40.1 do not apply to services performed in a physician office laboratory or a qualified hospital laboratory.  Both circumstances are entirely outside the scope of all sections concerning referral laboratory services.   Every A/B MAC (B) shall process a claim for a referred laboratory service if submitted by an independent clinical laboratory with a physical presence within the A/B MAC (B)s jurisdiction, notwithstanding that the referred laboratory service may have been performed outside of its jurisdiction.  Every A/B MAC (B) shall maintain the clinical laboratory fee schedules for each A/B MAC (B) jurisdiction and be able to process claims using those fee schedules.  Every A/B MAC (B) shall base payment for a referred service on the fee schedule for the jurisdiction in which the service was performed, i.e., where the test was performed.  An exception to this rule allows a payment for a service that is A/B MAC (B) -priced to be based upon the price developed by the A/B MAC (B) processing the claim.  Every A/B MAC (B) that has previously assigned reference use only PINs to out -of-jurisdiction laboratories for the purpose of their billing referred services shall cancel such reference -use-only PINs.  A/B MACs (B) must use the numerical locality codes specified in 50.4 to identify the appropriate clinical diagnostic laboratory fee schedule for use in pricing a referred laboratory service.   50.2 - Physicians (Rev. 1, 10- 01-03) B3-4110.2  If a physician or medical group furnishes laboratory tests in an office setting and it is appropriate for them to be performed in the physicians office, no further development of the source of the laboratory tests is required.   If a claim or physicians bill raises a question as to the source of a laboratory test and it cannot be resolved from available information, A/B MACs (B) must request the source of the laboratory service from the physician.  If the clinical laboratory test is subject to the laboratory fee schedule, A/B MACs (B) must pay only the person or entity that performed or supervised the performance of the test.  However, A/B MACs (B) may also pay one physician for tests performed or supervised by another physician with whom he/she shares a practice, i.e., the two physicians are members of a medical group whose physicians submit claims in their own names rat her than in the name of the group.  Where the medical group submits claims in the name of the group for the services of the physician who performed or supervised the performance of these tests, A/B MACs (B) must pay the group.  Regardless of who submits th e claim, assignment is required for payment.  See 50.2.1 below.  50.2.1 - Assignment Required  (Rev.  3510, Issued: 04- 29-16, Effective: 10-01- 16, Implementation; 10-03-16)   Carriers must:   Pay for clinical laboratory services provided in the physicians office only on an assignment basis.   Treat as assigned any claims for clinical laboratory services provided in the physicians office even if the claimant submits the claim on a non- assigned basis or if the assignment option is not designated.   Deny claims where it is apparent from the claims form or from other evidence that the beneficiary or provider refuses to assign.    The contractor shall use the following remittance advice message and associated codes when rejecting/denying claims under this policy.  This CARC/RARC combination is compliant with CAQH CORE Business Scenario Three.  Group Code: CO or PR CARC: 111  RARC: N/A  MSN: 16.41 OR 16.6  50.3 - Hospitals  (Rev. 1, 10-01-03)  50.3.1 - Hospital -Leased Laboratories  (Rev. 1, 10-01-03) B3-4110.1  A/B MACs (B) process claims from hospital laboratories that are leased by physicians and independent laboratories.  Before processing claims for services furnished by a hospital laboratory department operated on a lease or concession basis by a pathologist or by a nonphysician specialist such as a biochemist (with a visiting pathologist or outside independent laboratory doing the hospitals tissue work), A/B MACs (B) must ascertain if the laboratory ha s been approved by the RO.  Services furnished by a laboratory that does not meet the hospital laboratory conditions of participation and is operated under a lease arrangement in a domestic emergency hospital are covered only if they are emergency inpatient services payable under Par t A.  Additional information concerning nonparticipating emergency hospital services is found in Chapter 3.  50.3.2 - Hospital Laboratory Services Furnished to Nonhospital Patients  (Rev. 3014, Issued: 08- 06-14, Effective: ICD - 10: Upon Implementation of ICD -10 ASC- X12: 01- 01-12, Implementation: ICD -10: Upon Implementation of ICD -10 ASC X12: 09 -08-14)  When a hospital laboratory performs a laboratory service for a non- hospital patient, (i.e., for neither an inpatient nor an outpatient), the hospital bills its A/B MAC (A) on the ASC X12 837 institutional claim format or on the hard copy Form CMS -1450.  If  an A/B MAC (B) receives such claims, the A/B MAC (B) should deny them.  When the lab services are provided in Maryland, services to a hospitals own outpatients are paid under the State cost containment system.  A Maryland hospital cannot seek payment bas ed on a percent of charges for tests provided to individuals in locations such as a rural health clinic (RHC), a provider -based HHA, the individuals home or a physicians office).  Individuals in these locations are non- patients of the Maryland hospital a nd their lab tests would be categorized as non -patient specimen only lab tests (TOB 14x), and are paid under the lab fee schedule.   When a hospital -leased laboratory performs a service for a non -hospital patient, it must bill the A/B MAC (B).   50.4 - Reporting of Pricing Localities for Clinical Laboratory Services  (Rev.  3875, Issued: 10- 06-17, Effective: 01 -08-18, Implementation: 01- 08-18) PM-B-97-12  A/B MACs (B) shall report to the common working file (CWF) new State pricing localities (positions 58 and 59 on the A/B MAC (B) record) indicated on the Clinical Diagnostic Laboratory fee schedule for any reference laboratory service billed with a HCPCS 90  modifier.  If the laboratory test billed is not a reference laboratory service, the A/B MAC (B) Locality (location 11 -12) on the Clinical Diagnostic Laboratory fee schedule should be forwarded to the CWF.  For dates of service on or after April 1, 2004, CWF will not edit clinical laboratory pricing locality.   The A/B MAC (A) and (B) record layouts, plus the State pricing locations are as follows:   A/B MAC (B) RECORD LAYOUT FOR DATA FILE  CLINICAL LABORATORY FEE SCHEDULE  Data Element Name  Picture  Location  Comment  HCPCS Code  X(05)  1-5  Data Element Name  Picture  Location  Comment  A/B MAC (B) Number  X(05)  6-10  A/B MAC (B) Lo  X(02)  11-12 00--Single State A/B MAC (B)  01--North Dakota  02--South Dakota  02--South Dakota  20--Puerto Rico  60% Local Fee 9(05)V99  13-19  62% Local Fee  9(05)V99  20-26  60% Natl Limit Amt  9(05)V99  27-33  62% Natl Limit Amt  9(05)V99  34-40  60% Pricing Amt  9(05)V99  41-47  62% Pricing Amt  9(05)V99  48-54  Gap-Fill Indicator  X(01)  55-55 0  No Gap -fill Required  1-- A/B MAC (B) Gap -fill 2--Special Instructions Apply  Modifier  X(02)  56-57 Where modifier is shown, QW denotes  a CLIA waiver test  State Locality  X(02)  58-59 See attached  FILLER  X(01)  60   A/B MAC (A) RECORD LAYOUT FOR DATA FILE  CLINICAL LABORATORY FEE SCHEDULE  Data Element Name  Picture  Location  Comment  HCPCS  X(05)  1-5  Filler  X(04)  6-9  60% Pricing Amt  9(05)V99  10-16  62% Pricing Amt  9(05)V99  17-23  Filler  X(07)  24-30  A/B MAC (B) Number  X(05)  31-35  Data Element Name  Picture  Location  Comment  A/B MAC (B) Locality  X(02)  36-37 00--Single State A/B MAC (B)  01--North Dakota  02--South Dakota  20  Puerto Rico  State Locality  X(02)  38-39 See Attached  FILLER  X(21)  40-60   On or after January 1, 2018, t he record layouts  of the CLFS are as follows:    Data Element Name  Picture  Location  Comment  Year  PIC X(04)  1-4 Calendar year (YYYY) associated with the Clinical Lab Fee Schedule.  Filler  PIC X(01)  5 Value ' '  HCPCS Code  PIC X(05)  6-10 All current year active CPT and alpha -numeric codes subject to CLFS. Filler  PIC X(01)  11 Value ' '  Modifier  PIC X(02)  12-13 Where modifier is shown, QW denotes a CLIA waiver test.  Filler  PIC X(01)  14 Value ' '  Effective Date  PIC X(08)  15-22 Date the Clinical Lab Fee Schedule became effective (YYYYMMDD).  Filler  PIC X(01)  23 Value ' '  Indicator  PIC X(01)  24 National (N) or Local (L) payment indicator.  Filler  PIC X(01)  25 Value ' '  Payment Rate PIC Z9(05)V99  26-32 The payment amount associated with each test on the Clinical Lab Fee Schedule.  Filler  PIC X(01)  33 Value ' '  Description  PIC X(40)  34-73 Short description of the applicable HCPCS code.      CarrierLocality/StateLocality Map