OPPS Proposed Rule Bundles Laboratory Tests for the First Time

Clinical diagnostic laboratory tests have always been excluded from the outpatient prospective payment system (OPPS) but that will change if a proposed rule becomes final as it is currently written. On July 8, 2013, CMS released the 2014 OPPS proposed rule that includes a proposal to bundle laboratory tests into the existing service packages for hospital outpatients. All laboratory test are included with the exception of molecular pathology tests.

• The criteria for bundling includes when the laboratory tests are provided on the same date of service and are ordered by the same practitioner as the primary service.
• A laboratory test would be excluded from the packaging policy if it is unrelated to a primary service, or the laboratory test is the only service provided on that date of service, or the laboratory test is provided on the same date as the primary service but is ordered for a different purpose and by a different practitioner than the primary service.

What this means for laboratories is that for outpatients of the hospital, laboratory services that were previously separately billable directly to Medicare will now have to be billed to the hospital in those cases where the criteria above applies. The hospital will have to inform the laboratory whether the patient the tests are being ordered on is an outpatient of the hospital or not so the laboratory knows when to bill the hospital and when to bill Medicare directly. From a compliance perspective, the laboratory may find itself liable for duplicate payments if it does not bill these correctly. The rule will be published in the Federal Register on July 19, 2013.