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Printed Date: 9/22/2015
Clinical Diagnostic Laboratory Tests Submitted Under Arrangement
This information applies to every diagnostic clinical laboratory service that is payable under Medicare Part B. Neither the place where the service was performed nor the type of contractor that will process the request for payment has any effect on the applicability of these policies.
Date of Service: General Rule
The date of service of the test must be the date the specimen was collected.
If a specimen is collected over a period that spans two calendar days, the date of service must be the date the collection ended.
Three exceptions apply to the date of service policy for laboratory tests.
1. Date of service for test performed on stored specimens. If a specimen was stored for 30 calendar days or less from the date it was collected, the date of service of the test must be the date the test was performed only if:
If the specimen was stored for more than 30 calendar days before testing, the specimen is considered to have been archived and the date of service of the test must be the date the specimen was obtained from storage.
2. Date of service for Chemotherapy Sensitivity Tests Performed on Live Tissue. In the case of a chemotherapy sensitivity test performed on live tissue, the date of service of the test must be the date the test was performed only if:
A "chemotherapy sensitivity test" is defined as a test that requires a fresh tissue sample to test the sensitivity of tumor cells to various chemotherapeutic agents for the purposes of applying the above exception.
3. Date of service for Advanced Diagnostic Laboratory Tests and Molecular Pathology Tests. In the case of a molecular pathology test performed by a laboratory other than a blood bank or center, or a test designated by CMS as an ADLT under paragraph (1) of the definition of advanced diagnostic laboratory test in 42 CFR 414.502, the DOS must be the date the test was performed only if:
For the purpose of section 40.8.C, a “blood bank or center” means an entity whose primary function is the performance or responsibility for the performance of, the collection, processing, testing, storage and/or distribution of blood or blood components intended for transfusion and transplantation.
A valid diagnosis code must be included on all claims for laboratory services submitted by professional suppliers. This includes:
Palmetto GBA will accept up to eight diagnosis codes on electronic claims. Only four diagnosis codes may be submitted on paper claims.
Ordering practitioners include nonphysician practitioners such as clinical nurse specialists, clinical psychologists, clinical social workers, nurse midwives, nurse practitioners and physician assistants who furnish services that would be physician services if furnished by a physician, and who work within the scope of their authority under state law and within the scope of the Medicare statutory benefit.
The term "clear policy" means a statute, National Coverage Determination (NCD), coverage provision in an interpretive manual or Local Coverage Determination (LCD).
Clarification of the Use of the Terms "Screening" or "Screen"
There are two CPT modifiers that identify multiple tests for the same beneficiary on the same day. These modifiers are not interchangeable. Laboratories are responsible for providing documentation of medical necessity upon request.
CPT Code 82803: Gas, blood, any combination of pH, PCO2, PO2, CO2, HCO3, (including calculated 01 saturation).
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Last Updated: 01/07/2020