Notification

STAT Laboratory Tests Performed in the Outpatient Hospital Setting for Health Maintenance Organization (HMO) and Point of Service (POS) Products


Notification Issue Date: 05/24/2010

This is only a notification of the policy that will be in effect on 06/23/2010. For the current version of this policy, click the following link: 00.01.41, STAT Laboratory Tests Performed in the Outpatient Hospital Setting for Health Maintenance Organization (HMO) and Point of Service (POS) Products.



Claim Payment Policy


Title:STAT Laboratory Tests Performed in the Outpatient Hospital Setting for Health Maintenance Organization (HMO) and Point of Service (POS) Products

Policy #:00.01.41b

This policy is applicable to the Company’s commercial products only. Policies that are applicable to the Company’s Medicare Advantage products are accessible via a separate Medicare Advantage policy database.

Application of Claim Payment Policy is determined by benefits and contracts. Benefits may vary based on product line, group or contract. Medical necessity determination applies only if the benefit exists and no contract exclusions are applicable. Individual member benefits must be verified.

In products where members are able to self-refer to providers for care and services, members are advised to use participating providers in order to receive the highest level of benefits.When services can be administered in various settings, the Company reserves the right to reimburse only those services that are furnished in the most appropriate and cost-effective setting that is appropriate to the member’s medical needs and condition. This decision is based on the member’s current medical condition and any required monitoring or additional services that may coincide with the delivery of this service.

For more information on how Claim Payment Policy Bulletins are developed, go to the About This Site section of this Medical Policy Web site.



Policy

For Health Maintenance Organization (HMO) and Point of Service (POS) products, STAT laboratory (lab) tests performed in an outpatient hospital setting are covered and eligible for reimbursement consideration by the Company when they are performed to obtain immediate results to assist in determining an individual's course of treatment. For a list of eligible STAT lab tests, refer to Attachment A.


Precertification and referrals are not required for the STAT lab tests listed in Attachment A. These tests may be performed by any participating hospital laboratory, provided that a participating provider (ie, the individual's primary care physician [PCP] or specialist) requests the STAT lab test via a written order.

Lab tests that are not included in Attachment A require precertification if they are to be performed on a STAT basis. When ordered in conjunction with STAT lab tests, routine lab tests require precertification in order to be eligible for additional reimbursement consideration.


Guidelines

Participating primary care physicians (PCP) and specialists may direct any STAT laboratory (lab) test to any participating hospital with a written physician order.


Routine lab tests and those not listed in Attachment A must be directed to the PCP-designated laboratory site for Health Maintenance Organization (HMO) and Point of Service (POS) products.

In geographic areas with a capitated lab program, STAT lab tests listed in Attachment A and performed in an outpatient hospital setting that is the member's designated cap site are included in the capitation payment and are, therefore, not eligible for separate reimbursement.


Description

Laboratory (lab) testing is an important component of clinical treatment and is performed to provide information for the diagnosis, prevention, or treatment of disease, or the assessment of an individual’s health.


At times, it may be necessary for providers to perform specific laboratory tests to obtain immediate results to assist in determining the individual's course of treatment. These tests are defined as STAT lab tests and are performed in the outpatient hospital setting.


References


Company benefit contracts.

Partners in Health. Provider Manual. November 2006.




Coding

Inclusion of a code in this table does not imply reimbursement. Eligibility, benefits, limitations, exclusions, precertification/referral requirements, provider contracts, and Company policies apply.

The codes listed below are updated on a regular basis, in accordance with nationally accepted coding guidelines. Therefore, this policy applies to any and all future applicable coding changes, revisions, or updates.

In order to ensure optimal reimbursement, all health care services, devices, and pharmaceuticals should be reported using the billing codes and modifiers that most accurately represent the services rendered, unless otherwise directed by the Company.

The Coding Table lists any CPT, ICD-9, ICD-10, and HCPCS billing codes related only to the specific policy in which they appear.

CPT Procedure Code Number(s)

Refer to Attachment A for a listing of STAT laboratory tests.


Professional and outpatient claims with a date of service on or before September 30, 2015, must be billed using ICD-9 codes. Professional and outpatient claims with a date of service on or after October 1, 2015, must be billed using ICD-10 codes.

Facility/Institutional inpatient claims with a date of discharge on or before September 30, 2015, must be billed with ICD-9 codes. Facility/Institutional inpatient claims with a date of discharge on or after October 1, 2015, must be billed with ICD-10 codes.


ICD-10 Procedure Code Number(s)

N/A


Professional and outpatient claims with a date of service on or before September 30, 2015, must be billed using ICD-9 codes. Professional and outpatient claims with a date of service on or after October 1, 2015, must be billed using ICD-10 codes.

Facility/Institutional inpatient claims with a date of discharge on or before September 30, 2015, must be billed with ICD-9 codes. Facility/Institutional inpatient claims with a date of discharge on or after October 1, 2015, must be billed with ICD-10 codes.


ICD-10 Diagnosis Code Number(s)

N/A


HCPCS Level II Code Number(s)

N/A


Revenue Code Number(s)

N/A

Coding and Billing Requirements


Cross References

Attachment A: STAT Laboratory Tests Performed in the Outpatient Hospital Setting for Health Maintenance Organization (HMO) and Point of Service (POS) Products


Policy History

Effective 10/05/2017 this policy has been updated to the new policy template
format.
Version Effective Date: 01/01/2015
Version Issued Date: 02/09/2015
Version Reissued Date: N/A

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Independence Blue Cross is an independent licensee of the Blue Cross and Blue Shield Association, serving the health insurance needs of Philadelphia and southeastern Pennsylvania.