Billing tips for Laboratory claims in CMS 1500
1. Involving EKG tracing and the procurement of specimen(s) from a patient at home or in an institution, if the claim does not contain a validation from the prescribing physician that any laboratory service(s) performed were conducted at home or in an institution by entering the appropriate annotation in item 19 (i.e., “Homebound”). (Remark code MA116 is used.)
2. If the name, address, and ZIP Code where the test was performed is not entered in item 32, if the services were performed in a location other than the patient’s home or physician’s office. (Remark code MA114 is used.) Effective for claims received on or after April 1, 2004, the name, address, and ZIP Code of the service location for all services other than those furnished in place of service home – 12 must be entered.
3. When a diagnostic service is billed as an anti-markup service and the service is purchased from another billing jurisdiction, the billing physician or supplier must submit the name, address, and ZIP Code of the performing physician or supplier in Item 32, and the NPI of the performing physician or supplier in Item 32a. If Items 32 and 32a are not entered, remark code MA114 is used.
For all laboratory services, if the services of a referring/ordering physician, physician’s assistant, nurse practitioner, clinical nurse specialist are used and his or her name is not present in items 17 or in 17a. or if the NPI is not entered in item 17b. of the Form CMS-1500. (Remark code N264 or N286 is used.)
For laboratory services performed by a participating hospital-leased laboratory or independent laboratory in a hospital, clinic, laboratory, or facility other the patient’s home or physician’s office (including services to a patient in an institution), if the name, address, and ZIP Code of the location where services were performed is not entered in item 32. (Remark code MA114 is used.) Effective for claims received on or after April 1, 2004, the name, address, and ZIP Code of the service location for all services other than those furnished in place of service home – 12 must be entered.
For all laboratory work performed outside a physician’s office, if the claim does not contain a name, address, and ZIP Code for where the laboratory services were performed in item 32 or if the NPI is not entered into item 32a of the Form CMS-1500 if the services were performed at a location other than the place of service home – 12. (Use Remark code MA114)
For all physician office laboratory claims, if a 10-digit CLIA laboratory identification number is not present in item 23. This requirement applies to claims for services performed on or after January 1, 1998. (Remark code MA120 is used.)
Laboratory Billing Guidelines
Using Preferred Reference Labs
All providers participating in the Preferred Care PPO network must refer members to preferred reference lab vendors when lab services are needed and are not performed in the provider’s office. Physicians who do not adhere to these referral guidelines may be subject to penalties as described in their provider contracts.
Please refer to the preferred lab requirements listed below to ensure your patients with Preferred Care PPO coverage receive the maximum benefits to which they are entitled. A list of preferred reference labs that must be used is also included in this manual. Preferred Labs We use a preferred lab program with multiple statewide and regional lab vendors. Laboratory services provided to Preferred Care PPO Louisiana members must be submitted to one of the following labs:
* Please note that this is the current list of preferred statewide and regional reference labs as of the date this manual was published. To view the most current list of preferred labs, visit our website at www.bcbsla.com/providers >Doctor & Hospital Search and enter the member’s ID number or network, City, Parish or Zip, type Laboratory for Specialty or Keyword and click search.
Working With Preferred Reference Labs
Contact preferred reference labs directly to obtain the necessary forms for submitting lab services for your PPO patients.
Physicians who do not collect specimens in their offices may refer their PPO patients to a preferred reference lab draw site. You may use our online provider directories available at www.bcbsla.com or the list included in this manual to locate preferred reference lab draw sites. No specimen collection billing would be appropriate in this situation.
Out-of-state Labs
If you refer your patients to a reference lab that is not in Louisiana, the out-of-state reference lab must be a participating provider for the member’s plan in the state where the specimen is drawn in order for the member to receive the highest level of member benefits. If you are collecting the specimen* and sending the specimen to an out-of-state reference lab, you need to ensure that the out-of-state reference lab you are using is participating with Blue Cross and Blue Shield of Louisiana, otherwise your patient will be subject to a much higher cost share for this service. In addition, using a non-participating reference lab could subject you to a lower allowable charge.
Ordering Physician Requirements
The ordering/referring provider NPI is required on all laboratory claims otherwise the claim will be returned requesting that the claim be refiled with the ordering provider’s NPI number. If you are CLIA certified to provide lab services in your office and you are billing Blue Cross for these services, please include the ordering provider NPI information on the claim form. For more information on NPIs, visit www.bcbsla.com/providers >NPI. Place the NPI in the indicated blocks of the referenced claim forms:
• CMS -1500: Block 17A
• UB-04: Block 78
• 837P: 2310A loop, using the NM1 segment and the qualifier of DN in the NM101 element
• 837I: 2310D loop, segment NM1 with the qualifier of DN in the NM101 element
Scenario
An independent laboratory receives and processes the Louisiana member’s blood specimen. The member’s blood was drawn in Louisiana* but processed in Texas by a reference lab. The out-of-state reference lab should file the claim to Blue Cross and Blue Shield of Louisiana; the service area where the specimen was drawn. The Texas reference lab should be participating with Blue Cross and Blue Shield of Louisiana in order for the member to receive the highest level of benefits. *Where the specimen was drawn will be determined by which state the referring provider is located.
Pass-Through Billing Not Permitted
Pass-through billing occurs when the ordering provider requests and bills for a lab service, but the lab service is not performed by the ordering provider or the CLIA-certified lab owned and operated by the ordering provider. The expectation is that we will receive lab claims billed from:
• The performing provider at a CLIA-certified lab, owned and operated by the ordering physician, or
• The ordering provider who owns and operates a CLIA-certified lab, or
• An in-network reference lab
Blue Cross and HMO Louisiana do not permit pass-through billing. Only the performing provider should bill for these services. You may only bill for lab services that you perform in your office. Providers may bill for the following indirectly performed services:
• The service of the performing provider is performed at the place of service of the ordering provider and is billed by the ordering provider, or
• The service is provided by an employee of a physician or other professional provider (e.g. physician assistant, surgical assistant, advanced practice nurse, clinical nurse specialist, certified nurse midwife or registered nurse first assistant), who is under the direct supervision of the ordering provider and the service is billed by the ordering provider.
1. Involving EKG tracing and the procurement of specimen(s) from a patient at home or in an institution, if the claim does not contain a validation from the prescribing physician that any laboratory service(s) performed were conducted at home or in an institution by entering the appropriate annotation in item 19 (i.e., “Homebound”). (Remark code MA116 is used.)
2. If the name, address, and ZIP Code where the test was performed is not entered in item 32, if the services were performed in a location other than the patient’s home or physician’s office. (Remark code MA114 is used.) Effective for claims received on or after April 1, 2004, the name, address, and ZIP Code of the service location for all services other than those furnished in place of service home – 12 must be entered.
3. When a diagnostic service is billed as an anti-markup service and the service is purchased from another billing jurisdiction, the billing physician or supplier must submit the name, address, and ZIP Code of the performing physician or supplier in Item 32, and the NPI of the performing physician or supplier in Item 32a. If Items 32 and 32a are not entered, remark code MA114 is used.
For all laboratory services, if the services of a referring/ordering physician, physician’s assistant, nurse practitioner, clinical nurse specialist are used and his or her name is not present in items 17 or in 17a. or if the NPI is not entered in item 17b. of the Form CMS-1500. (Remark code N264 or N286 is used.)
For laboratory services performed by a participating hospital-leased laboratory or independent laboratory in a hospital, clinic, laboratory, or facility other the patient’s home or physician’s office (including services to a patient in an institution), if the name, address, and ZIP Code of the location where services were performed is not entered in item 32. (Remark code MA114 is used.) Effective for claims received on or after April 1, 2004, the name, address, and ZIP Code of the service location for all services other than those furnished in place of service home – 12 must be entered.
For all laboratory work performed outside a physician’s office, if the claim does not contain a name, address, and ZIP Code for where the laboratory services were performed in item 32 or if the NPI is not entered into item 32a of the Form CMS-1500 if the services were performed at a location other than the place of service home – 12. (Use Remark code MA114)
For all physician office laboratory claims, if a 10-digit CLIA laboratory identification number is not present in item 23. This requirement applies to claims for services performed on or after January 1, 1998. (Remark code MA120 is used.)
Laboratory Billing Guidelines
Using Preferred Reference Labs
All providers participating in the Preferred Care PPO network must refer members to preferred reference lab vendors when lab services are needed and are not performed in the provider’s office. Physicians who do not adhere to these referral guidelines may be subject to penalties as described in their provider contracts.
Please refer to the preferred lab requirements listed below to ensure your patients with Preferred Care PPO coverage receive the maximum benefits to which they are entitled. A list of preferred reference labs that must be used is also included in this manual. Preferred Labs We use a preferred lab program with multiple statewide and regional lab vendors. Laboratory services provided to Preferred Care PPO Louisiana members must be submitted to one of the following labs:
* Please note that this is the current list of preferred statewide and regional reference labs as of the date this manual was published. To view the most current list of preferred labs, visit our website at www.bcbsla.com/providers >Doctor & Hospital Search and enter the member’s ID number or network, City, Parish or Zip, type Laboratory for Specialty or Keyword and click search.
Working With Preferred Reference Labs
Contact preferred reference labs directly to obtain the necessary forms for submitting lab services for your PPO patients.
Physicians who do not collect specimens in their offices may refer their PPO patients to a preferred reference lab draw site. You may use our online provider directories available at www.bcbsla.com or the list included in this manual to locate preferred reference lab draw sites. No specimen collection billing would be appropriate in this situation.
Out-of-state Labs
If you refer your patients to a reference lab that is not in Louisiana, the out-of-state reference lab must be a participating provider for the member’s plan in the state where the specimen is drawn in order for the member to receive the highest level of member benefits. If you are collecting the specimen* and sending the specimen to an out-of-state reference lab, you need to ensure that the out-of-state reference lab you are using is participating with Blue Cross and Blue Shield of Louisiana, otherwise your patient will be subject to a much higher cost share for this service. In addition, using a non-participating reference lab could subject you to a lower allowable charge.
Ordering Physician Requirements
The ordering/referring provider NPI is required on all laboratory claims otherwise the claim will be returned requesting that the claim be refiled with the ordering provider’s NPI number. If you are CLIA certified to provide lab services in your office and you are billing Blue Cross for these services, please include the ordering provider NPI information on the claim form. For more information on NPIs, visit www.bcbsla.com/providers >NPI. Place the NPI in the indicated blocks of the referenced claim forms:
• CMS -1500: Block 17A
• UB-04: Block 78
• 837P: 2310A loop, using the NM1 segment and the qualifier of DN in the NM101 element
• 837I: 2310D loop, segment NM1 with the qualifier of DN in the NM101 element
Scenario
An independent laboratory receives and processes the Louisiana member’s blood specimen. The member’s blood was drawn in Louisiana* but processed in Texas by a reference lab. The out-of-state reference lab should file the claim to Blue Cross and Blue Shield of Louisiana; the service area where the specimen was drawn. The Texas reference lab should be participating with Blue Cross and Blue Shield of Louisiana in order for the member to receive the highest level of benefits. *Where the specimen was drawn will be determined by which state the referring provider is located.
Pass-Through Billing Not Permitted
Pass-through billing occurs when the ordering provider requests and bills for a lab service, but the lab service is not performed by the ordering provider or the CLIA-certified lab owned and operated by the ordering provider. The expectation is that we will receive lab claims billed from:
• The performing provider at a CLIA-certified lab, owned and operated by the ordering physician, or
• The ordering provider who owns and operates a CLIA-certified lab, or
• An in-network reference lab
Blue Cross and HMO Louisiana do not permit pass-through billing. Only the performing provider should bill for these services. You may only bill for lab services that you perform in your office. Providers may bill for the following indirectly performed services:
• The service of the performing provider is performed at the place of service of the ordering provider and is billed by the ordering provider, or
• The service is provided by an employee of a physician or other professional provider (e.g. physician assistant, surgical assistant, advanced practice nurse, clinical nurse specialist, certified nurse midwife or registered nurse first assistant), who is under the direct supervision of the ordering provider and the service is billed by the ordering provider.