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Pathology/Lab Coding Alert

You be the Coder:

Physician's Office or Lab - Who Bills?

Published on Wed Mar 01, 2000

Test your coding knowledge. Determine how you would code this situation before looking at the box below for the answer.

Question: Our physician office lab sent some tests to a local hospital lab for after-hours processing. We were expecting the hospital to bill the carrier (Medicare in some cases). The hospital lab is billing us, however, telling us to bill directly for our reimbursement. I believe there is a Medicare rule against this, but I cant find it. Could you please clarify this and provide some documentation that I can show to the hospital lab?

Anonymous Michigan Subscriber
 

Answer: Assuming that your situation does not fall under the few Medicare exceptions, you are correct. The hospital lab must bill Medicare for the services it provides. The documentation can be found in Medicare Carriers Manual Part 3 section 5114.1 (E), Who Can Bill and Receive Payment for Clinical Laboratory Tests? The general principal stated here is that payment is only made to the person or entity which performed or supervised the performance of the tests. There are three exceptions that would allow your physicians office to bill for the lab tests done by the hospital. These are: 1) if you are part of a rural hospital, 2) if there is an ownership relationship between your physicians practice and the hospital lab that performs the test, and 3) less than 30 percent of all your requests for lab tests throughout the year are referred to another lab. Please refer to the MCM or contact your local carrier for more specific direction if you think you might meet one of the exceptions.
 


 

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