Critical access hospitals and billing for non-patient laboratory testing

In a May 12 post, clarification was given regarding a “non-patient” and reference laboratory testing.  Continuing with this discussion, critical access hospitals (CAH) also received good news in Transmittal 1729 to the Claims Processing Manual, dated May 8, 2009.  Under Section 148 of MIPPA (Medicare Improvements for Patients and Providers Act), a CAH will be paid 101% of reasonable cost for outpatient clinical diagnostic laboratory tests for those patients who are not physically present in the CAH at the time the specimen is collected.  These patients are referred to as “non-patients” since only a specimen is received for the date of service.  Prior to this transmittal, all hospitals providing laboratory services to “non-patients” were instructed to bill on Type of Bill (TOB) 14X which triggered reimbursement under the Clinical Laboratory Fee Schedule.

Effective for dates of service on or after July 1, 2009, the patient must receive outpatient services in the CAH on the same day that the specimen is collected OR the specimen must be collected by an employee of the CAH.  If either of these two criteria is met, the CAH may submit a TOB 85X for the lab and reimbursement will be made at 101% of reasonable cost.  When a patient is physically present in the CAH or in a provider based facility of the CAH, then neither of these two conditions apply.  For “non-patients” who do not meet either of these criteria, laboratory tests must be billed on TOB 14X and will continue to be paid on the clinical laboratory fee schedule.  If the patient is in a SNF and the CAH employee goes to that location to collect the specimen, reimbursement under the 101% of reasonable cost methodology will only occur once the patient has exhausted their Medicare Part A benefits. As in the past, beneficiaries will not have to pay any coinsurance, copayment, or deductibles for laboratory services.

In order for CAHs to receive the improved reimbursement for “non-patients” that meet the above criteria, they are responsible for submitting the services on TOB 85X.  Your FI/MAC is responsible for payment under the correct methodology based the bill type the facility submits.  Presumably, if the CAH has incorrectly submitted claims with dates of service July 1, 2009, forward, a corrected claim may be submitted to receive the appropriate reimbursement under either the cost based or the fee schedule methodology.  The billing staff and lab personnel should carefully review their registration processes to clearly identify those patients who qualify for the change in reimbursement.