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Guidance on Coding and Billing Date of Service on Professional Claims - Reissued

MLN Matters Number: SE17023 Reissued
Article Release Date: January 24, 2019

Note: This article was reissued on January 24, 2019, to clarify information

Radiology Services

Typically, radiology services have two separate components: a professional and a technical component. These services will have a PC/TC indicator of “1” on the Medicare Physician Fee Schedule (MPFS) Relative Value File. The technical component is billed on the date the patient had the test performed. When billing a global service, the provider can submit the professional component with a date of service reflecting when the review and interpretation is completed or can submit the date of service as the date the technical component was performed. This will allow ease of processing for both Medicare and the supplemental payers. If the provider did not perform a global service and instead performed only one component, the date of service for the technical component would the date the patient received the service and the date of service for the professional component would be the date the review and interpretation is completed.

Surgical and Anatomical Pathology

Surgical and anatomical pathology services may have two components: a professional and a technical component. These services will have a PC/TC indicator of “1” on the MPFS Relative Value File. The technical component is billed on the date the specimen was collected. This would be the surgery date. When billing a global service, the provider can submit the professional component with a date of service reflecting when the review and interpretation is completed or can submit the date of service as the date the technical component was performed. This will allow ease of processing for both Medicare and the supplemental payers. If the provider did not perform a global service and instead performed only one component, the date of service for the technical component would the date the patient received the service and the date of service for the professional component would be the date the review and interpretation is completed.

When the collection spans two calendar dates, use the date the specimen collection ended. There are exceptions for stored specimens as follows:

Stored specimens

In the case of a test/service performed on a stored specimen, if a specimen was stored for less than or equal to 30 calendar days from the date it was collected, the DOS of the test/service must be the date the test/service was performed only if:

  • The test/service is ordered by the patient’s physician at least 14 days following the date of the patient’s discharge from the hospital
  •  The specimen was collected while the patient was undergoing a hospital surgical procedure
  • It would be medically inappropriate to have collected the sample other than during the hospital procedure for which the patient was admitted
  • The results of the test/service do not guide treatment provided during the hospital stay; and
  • The test/service was reasonable and medically necessary for treatment of an illness.

If the specimen was stored for more than 30 calendar days before testing, the specimen is considered to have been archived and the DOS of the test/service must be the date the specimen was obtained from storage.

Clinical Laboratory Services

Generally, the date of service for clinical laboratory services is the date the specimen was collected. If the specimen is collected over a period that spans two calendar dates, the date of service is the date the collection ended. There are three exceptions to the general date of service rule for clinical laboratory tests:

1. Date of service for tests/services performed on stored specimens

In the case of a test/service performed on a stored specimen, if the specimen was stored less than or equal to 30 calendar days from the date it was collected, the date of service of the test/service must be the date the test/service was performed only if:

  • The test/service was ordered by the patient’s physician at least 14 days following the date of the patient’s discharge from the hospital;
  • The specimen was collected while the patient was undergoing a hospital surgical procedure;
  • It would be medically inappropriate to have collected the sample other than during the hospital procedure for which the patient was admitted;
  • The results of the test/service do not guide treatment provided during the hospital stay; and
  • The test/service was reasonable and necessary for the treatment of an illness.

If the specimen was stored for more than 30 calendar days before testing, the specimen is considered to have been archived and the date of service of the test/service must be the date the specimen was obtained from storage.

2. Date of service for chemotherapy sensitivity tests/services performed on live tissue

In the case of a chemotherapy sensitivity test/service performed on live tissue, the date of service of the test/service must be the date the test/service was performed only if:

  • The decision as to the specific chemotherapy agent to test is made at least 14 days after discharge;
  • The specimen was collected while the patient was undergoing a hospital surgical procedure;
  • It would be medically inappropriate to have collected the sample other than during the hospital procedure for which the patient was admitted;
  • The results of the test/service do not guide treatment provided during the hospital stay; and The test/service was reasonable and medically necessary for treatment of an illness.

3. Date of service for advanced diagnostic laboratory tests (ADLTs) and molecular pathology tests

In the case of a molecular pathology test or a test designated by CMS as an ADLT under paragraph (1) of the definition of advanced diagnostic laboratory test in 42 CFR 414.502, the date of service must be the date the test was performed only if:

  • The test was performed following a hospital outpatient’s discharge from the hospital outpatient department;
  • The specimen was collected from a hospital outpatient during an encounter;
  • It was medically appropriate to collect the sample from the hospital outpatient during the hospital outpatient encounter;
  • The results of the test do not guide treatment provided during the hospital outpatient encounter; and
  • The test was reasonable and necessary for the treatment of an illness.

INDUSTRY NEWS TAGS: CMS


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