Billing hospital outpatient laboratory services for BCN Advantage members

Effective Jan. 1, 2014, CMS changed the way laboratory services are paid in an outpatient hospital setting. CMS now packages outpatient hospital laboratory services when those services are integral to, ancillary to, supportive of, dependent on or adjunctive to a primary service or procedure. BCN AdvantageSM outpatient hospital claim processing mirrors Medicare methodology. Hospitals (including provider-based designations) are reminded that laboratory services denied as packaged may not be submitted to JVHL, BCN’s laboratory services vendor, for payment. Sending those claims to JVHL is considered unbundling. Laboratory tests may be billed on a TOB 014x claim and submitted to JVHL in the following instances:

Non-patient laboratory specimen tests

Laboratory-only services when no other service is rendered during the same encounter

Tests that are rendered with other hospital services during the same encounter, but are not related to the other hospital services and that were ordered by a different practitioner

The CMS guidelines are found in the CMS MLN Matters article MM8572. It is the hospital’s responsibility to determine when laboratory tests may be separately billed on a 014x claim under the limited exceptions outlined by CMS. In addition, molecular pathology tests represented by CPT codes *81200 to *81383, *81400 to *81408, and *81479 should be billed using a 013x type of bill.

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