Update to 2014 Hospital Outpatient Clinical Diagnostic Laboratory Test Payment and Billing

In the January 2014 update to the Hospital Outpatient Prospective Payment System (OPPS), CMS implemented a new policy under the 2014 OPPS final rule, providing packaged payment of outpatient lab tests (other than molecular pathology) under the OPPS rather than separate CLFS payment, effective for dates of service on or after January 1, 2014. In the Medicare claims system, packaged payment would apply to all lab tests (other than molecular pathology) billed by OPPS hospitals on a 013X Type of Bill (TOB) (Hospital Outpatient). As per the OPPS final rule, CMS created very limited exceptions to the packaging policy and instructed hospitals to use the 014X TOB (Hospital Non-Patient) to obtain separate payment only under certain circumstances. Since publication of the final rule and the January release of CR 8572, some hospitals expressed concern that submitting a 014x TOB in this manner may violate HIPPA. The National Uniform Billing Committee (NUBC) definition approved in 2005 for the 014x TOB for billing of laboratory services provided to “Non-Patients,” means referred specimen, where the patient is not present at the hospital. This article updates the operational mechanism OPPS hospitals should use to bill Medicare on or after July 1, 2014, for outpatient clinical diagnostic laboratory tests (lab tests) furnished in CY 2014 that are eligible for separate payment under the Clinical Laboratory Fee Schedule (CLFS). A new modifier will be used on the 013X TOB (instead of the 014X TOB) when non-referred lab tests are eligible for separate payment under the CLFS for certain exceptions. The 014x will only be used for non-patient (meaning referred) laboratory specimens and will not include this new modifier. The new modifier will be effective for claims received on or after July 1, 2014, and retroactive for dates of service on or after January 1, 2014. Please note that CMS views this new modifier as an immediate solution to hospitals’ concern for CY 2014.

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