MEDICARE (CMS) LAW

Under Medicare (CMS) law, MLabs cannot bill Medicare for technical charges if the order date is less than 14 days after the patient was classified as a hospital inpatient or outpatient, or was an inpatient in a Skilled Nursing Facility (SNF) in a Medicare paid bed, except for molecular pathology testing (CPT code range 81105 - 81479) collected from a hospital outpatient. See the chart below.

If a specimen was obtained in a private physician office (not billing under a facility tax ID), MLabs can bill Medicare directly for both technical and professional services (unless the patient was also in a SNF Medicare paid bed on the date of service or hospice).

 

 

MEDICARE 14-DAY RULE

Billing Guide

BILLING SCENARIOS

TRADITIONAL MEDICARE EXAMPLES

 

  • Charges for laboratory testing on a specimen collected from a hospital inpatient or ordered within 14 days of discharge will be billed to the referring client or facility (considered part of the Medicare inpatient DRG payment to the hospital).
     
  • Charges for laboratory testing on a specimen collected from a hospital outpatient or ordered within 14 days of the outpatient visit will be billed to the referring client or facility (considered part of the Medicare OPPS payment to the hospital).
     
  • Exception: charges for laboratory testing which falls in the Molecular Pathology CPT code range or ADLTs ordered on a specimen collected from a hospital outpatient will be billed directly to Medicare.
     
  • Charges for laboratory testing on a specimen collected from a patient in a private physician office or at an MLabs blood draw site with no hospital visit on the date of collection (patient is classified as a nonpatient) will be billed directly to Medicare.
  • Charges for professional services, e.g., second opinion consult cases CPT code 88321, will be billed directly to Medicare regardless of patient status (inpatient, outpatient, or nonpatient).
     
  • Consultations may require the addition of special stains and/or immunohistochemical (IHC) stains in order to render a diagnosis and in some cases may triage to molecular diagnostics testing. For second opinion consult cases from Medicare inpatients or outpatients which are triaged for additional special stains, MLabs will bill the professional fees directly to Medicare and will bill the technical charges to the client or referring facility commonly termed “split billing”. (Note that split billing has not been implemented for Molecular Pathology or Flow Cytometry testing at this time).