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Laboratory Services Billed by Physicians

Reimbursement Policy:
Laboratory Services Billed by Physicians

Effective Date:
February 25, 2019

Purpose:
Provide guidelines for technical/professional component part of laboratory services when appropriately billed by professional providers.

Scope:
All products are included, except

  • Products where Horizon BCBSNJ is secondary to Medicare (e.g. Medigap)
  • COB
  • ITS Home In-Network
  • FEP
  • SHBP non MA

All Insured Individual, Commercial medical plans, and Medicare Advantage Plans, are included.

ASO accounts will be included as an Opt-In option for additional claims editing on an account-by-account basis

Policy:
Technical/Professional Component of Laboratory Services (procedure codes 80000-89999) billed in a Facility Setting
In accordance with CMS guidelines, Horizon BCBSNJ shall not consider for separate reimbursement the technical and/or professional component of laboratory services when billed by a professional provider and performed in the following facility settings:

  • 19 (Outpatient hospital-off campus)
  • 21 (Inpatient hospital)
  • 22 (Outpatient hospital-on campus)
  • 23 (Emergency room)
  • 51 (Inpatient psychiatric facility)
  • 52 (Psychiatric facility-partial hospitalization)
  • 61 (Comprehensive inpatient rehabilitation facility) or
  • 81 (Independent laboratory)

Reimbursement of the professional component only of laboratory services shall be considered for reimbursement for the following specialties when performed in a facility setting:

  • Dermatology
  • Genetics
  • Hematology
  • Laboratory
  • Pathology

Procedure Code 85060 (Interpretation of Blood Smears)
In accordance with CMS guidelines, Horizon BCBSNJ shall consider for reimbursement procedure code 85060 when performed by a professional provider and when services are rendered in the following facility settings:

  • 19 (Outpatient hospital-off campus)
  • 21 (Inpatient hospital)
  • 22 (Outpatient hospital-on campus)
  • 23 (Emergency department), or
  • 24 (ASC)

Horizon BCBSNJ shall consider for reimbursement procedure code 85060 when this service is performed by Hematology or Oncology specialist and rendered in an office or facility setting.

Procedure:
Horizon BCBSNJ shall deny the technical component of laboratory services (CPT® codes 80000-89999) when performed by a professional provider when services are rendered in the facility settings previously identified above.

Horizon BCBSNJ shall deny the professional component of laboratory services (CPT codes 80000-89999) when performed by a professional provider with a specialty other than Dermatology, Genetics, Hematology, Laboratory, or Pathology when rendered in the facility settings previously identified above.

Horizon BCBCSNJ shall deny procedure code 85060 when performed by a professional provider when the service is not performed in the facility settings previously identified above.

No additional reimbursement will be made if the provider is capitated or the reimbursement structure for that provider is a global fee.

In instances where the provider is participating, based on member benefits, co-payment, coinsurance, and/or deductible shall apply.

In denied instances where the provider is participating there shall be no member liability.

In instances where the provider is not participating, member liability shall be up to the provider’s charge.

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.

History:
01/22/2018: Policy approved

CPT® is a registered trademark of the American Medical Association.

Policy 119_v1.0_01222018