The following policy addresses Blue Cross Blue Shield North Dakota (BCBSND) general guidelines for lab services, lab bundling, and related services such as visits in addition to lab tests, purchased outside lab, repeat lab, and BlueCard lab billing.
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.
Laboratory and pathology procedures should be submitted using the CPT or HCPCS code(s) that best describe the service(s). CPT Codes 80047-89398 encompass the majority of laboratory and pathology procedures.
Organ or Disease Panels are tests listed under each lab panel (80047-80076) and identify the defined components (lab tests) of that panel.
The services listed in the pathology and laboratory section of the CPT manual 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.
The guidelines outlined below should be adhered to when submitting laboratory services to BCBSND.
A level-of-service office visit (such as 99201-99215) may be submitted in addition to laboratory tests only when additional separately identifiable services are provided.
Organ or Disease-Oriented Panels
The tests listed under each panel (80047-80076) 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 (1) line item, with one (1) unit 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 (not 59). 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.
Procedure Code Unbundling:
Procedure code unbundling is the submission of multiple procedure codes for a group of specific procedures that are components of a single comprehensive code. Procedure unbundling may occur when a professional claim could be submitted that has procedure codes for both the individual components, and the procedure code for the comprehensive procedure. BCBSND would reject the individual component codes as related to the comprehensive procedure code for payment.
Purchased Services/Outside Lab
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. It is important to remember that only one provider may bill for the service.
Repeat Lab Services
Repeat services require modifier -91 (not -59), unless the narrative supports submission of multiple units.
Lab Billed through the BlueCard® Program
Blue Plans* may contract with providers outside of their exclusive service area for services provided to local
and BlueCard members within their own service area for independent clinical lab services. Blue Plans may not contract for such services for their members who receive services outside of their service area.
Providers who perform lab services should file the claim to the Blue Plan where the referring physician is located. The claim will be reimbursed based on provider’s participation status with that Blue Plan.
* Each local Blue Cross and/or Blue Shield plan is an independent licensee of the Blue Cross and Blue Shield Association
Limitations and 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, 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.