The following policy addresses Blue Cross Blue Shield of North Dakota (BCBSND) reimbursement guidelines for laboratory services.
The services listed in the pathology and laboratory sections of the Current Procedural Terminology (CPT) and Healthcare Common Procedure Coding System (HCPCS) manuals may be provided by the pathologist or alternatively by technologists who are under the supervision of the pathologist or practitioner. Laboratory procedures should be submitted using the CPT or HCPCS code that best describes the service.
A medical or clinical laboratory is a facility equipped to perform tests on specimens obtained from a patient in order to diagnose, treat or prevent an illness. Specimens include but are not limited to blood, other body fluids, tissue specimens and organs. A variety of tests are available that pertain to chemistries, microbiology, hematology and genetics as well as anatomic pathology that includes macroscopic or gross pathology of specimens and organs as well as microscopic pathology that encompasses cytology, histology and electron microscopy of tissue samples.
An Evaluation and Management (E/M) level-of-service may be submitted in addition to laboratory tests only when additional separately identifiable services is provided.
The laboratory tests listed under each panel identify the defined components of that panel, and all tests listed must be performed in order to bill for that panel. Tests performed in addition to those specifically indicated for a particular panel can be billed separately in addition to the panel code. Lab panels should be reported as one line item, with a single unit of service per panel.
If a panel is submitted and one of the lab procedures/tests is repeated, that single repeat component may be billed with the individual service code and will require submission of modifier 91. Do not report two or more panel codes comprising the same tests; report the panel with the highest number of tests to meet the definition of the code and report the remaining tests individually.
Unbundling is the submission of multiple procedure codes for a group of specific procedures that are components of a single comprehensive code. BCBSND will reject the individual component codes as related to the comprehensive procedure code for payment.
Purchased & Outside Laboratory
The entity that performs a test should be the one to bill for that test. However, a provider may, under arrangement with another provider, bill a service that is purchased from that other provider. For example, a clinic may bill for a pap smear that is sent to an independent lab for analysis.
Note: Only one provider may bill for the service
Repeat Laboratory Services
When billing repeat laboratory services BCBSND requires modifier 91 to be used unless the narrative supports submission of multiple units.
Note: Modifier 59 is not acceptable
Limitations & Exclusions
While reimbursement is considered, payment determination is subject to, but not limited to:
- Group or Individual benefit
- Provider Participation Agreement
- Routine claim editing logic, including but not limited to incidental or mutually exclusive logic, payment integrity edits, and medical necessity
- Mandated or legislative required criteria will always supersede.
In instances where the provider is participating, based on member benefits, co-payment, coinsurance, and/or deductible shall apply.
Combined Lab Services: General Guidelines and Lab Re-Bundling into one policy. Minor language revisions including removal of reference to Stat Lab Charges and adding the Limitations and Exclusions section.
Updated policy to the new format and removed BlueCard program as it doesn’t apply to reimbursement.
Reviewed policy and updated the name of cross-referenced Correct Coding Guidelines – Commercial.
Annual review and added payment integrity edits to the limitations & exclusions