How to Bill Labs Across State Lines

When managing a primary or urgent care business that operates across multiple states, things can get complicated—especially when it comes to lab billing. A debate has surfaced around the correct way to complete a HCFA 1500 claim form when high-complexity lab services are run at a centralized location. Let’s walk through this scenario and clarify the most debated fields, with helpful tips to avoid claim denials.

Scenario Overview

Consider a healthcare organization with 20+ locations spread across states X and Y. All locations collect patient specimens and forward them to a central location in State X that holds a High Complexity CLIA certificate. This central site also functions as a traditional medical office where patients are seen and professional claims are submitted using Place of Service (POS) 11.

Here’s the twist: the same-day lab work is processed centrally, but patients might have been seen at a different location in a different state. This raises questions about the legitimacy of billing across state lines with matching dates of service. Let’s break down the specific HCFA fields and what they should include:

Key HCFA Fields and How to Fill Them

Box 17 – Referring Provider

This field should list the provider who ordered the test, which typically is the one who saw the patient and collected the specimen. It should not be the lab director or a provider at the testing site unless they were directly involved in patient care at the collection site.

Recommendation: Enter the NPI and name of the provider who actually saw the patient and initiated the lab order.

Box 24B – Place of Service

This field depends on what type of service is being billed:

Use POS 81 (Independent Lab) if billing for lab tests processed at the central testing site.
Use POS 11 (Office) for professional services (e.g., E/M) provided at any location where patients were seen.

Important Note: Do not mix the same POS for both professional and lab services on the same claim. Use separate claims when necessary.

Box 24J – Rendering Provider

For lab services, this should reflect the individual responsible for interpreting or performing the lab tests. Often this would be the lab director or supervising provider at the central testing site.

Tip: Use the NPI of the lab director or qualified physician overseeing the lab testing, not the referring provider or the provider who saw the patient at a different location.

Box 32 – Service Facility Location

This box should contain the physical address where the lab test was performed, which would be the centralized high-complexity CLIA-certified site in State X.

Warning: If this is filled incorrectly (e.g., with the patient’s visit location), it can result in payer confusion and possible denials.

What About Same-Day Services in Different States?

This is a common concern. Payers may flag claims if the same patient appears to have been seen in two different states on the same date of service. To mitigate this:

Ensure lab services are billed separately with POS 81 and centralized lab information.
Use appropriate modifiers (e.g., Modifier 90 for reference lab billing).
Consider slight date adjustments where medically appropriate (e.g., next-day processing).

Be aware that some payers may require pre-enrollment or registration of the lab facility under your NPI to recognize centralized testing locations.

Billing Tips for Laboratory Claims

Always verify that your CLIA number matches the type of testing billed.
Use Modifier QW for CLIA-waived tests where applicable.
Avoid duplicate billing by ensuring that lab and professional services are submitted on separate claims if they occur at different locations.
Double-check your taxonomy codes for billing as an independent laboratory versus an urgent care facility.
Maintain updated documentation of specimen collection, test requisitions, and results to support audits.

Conclusion

Multi-location urgent care organizations face unique billing challenges when it comes to lab services. By properly completing the HCFA form and adhering to CMS and payer guidelines, you can reduce denials and stay compliant across state lines.

If you’re in doubt, it’s always wise to consult a healthcare compliance expert or legal advisor experienced in lab billing regulations.