Answer: Beginning in calendar year (CY) 2014, payment for most laboratory tests (except for molecular pathology tests) will be packaged under the Outpatient Prospective Payment System (OPPS). The general rule for OPPS hospitals is laboratory tests should be reported on a 13x TOB. There are limited circumstances described below in which hospitals can separately bill for laboratory tests. For these specific situations the Centers for Medicare & Medicaid Services (CMS) expanded the use of the 14x TOB to allow separate billing and payment at CLFS rates for hospital outpatient laboratory tests.

Laboratory tests may be (or must be for a non-patient specimen) billed on a 14x TOB in the following circumstances:

  1. Non-patient laboratory specimen tests (non-patient continues to be defined as a beneficiary that is neither an inpatient nor an outpatient of a hospital, but that has a specimen that is submitted for analysis to a hospital and the beneficiary is not physically present at the hospital)
  2. When the hospital only provides laboratory test to the patient (directly or under arrangement) and the patient does not also receive other hospital outpatient services during that same encounter
  3. When the hospital provides a laboratory test (directly or under arrangement) during the same encounter as other hospital outpatient services that is clinically unrelated to the other hospital outpatient services, and the laboratory test is ordered by a different practitioner than the practitioner who ordered the other hospital outpatient services provided in the hospital outpatient setting. In this case the lab test would be billed on a 14X claim and the other hospital outpatient services would be billed on a 13X claim.

It will be the hospital’s responsibility to determine when laboratory tests may be separately billed on the 14X claim under these limited exceptions. In addition, laboratory tests for molecular pathology tests described by CPT codes in the ranges of 81200 through 81383, 81400 through 81408, and 81479 are not packaged in the OPPS and should be billed on a 13X type of bill.

Reference: Change Request (CR) 8572 (PDF, 265 KB)


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