Section
26
26
Independent Laboratory
26.1 Enrollment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
26.2 Clinical Laboratory Improvement Amendments (CLIA) . . . . . . . . . . . . . . . . . . . . . . . .
26.2.1 CLIA Requirements . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
26.2.2 CLIA Regulations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
26.2.3 Limits of Waiver and Physician-Performed Microscopy Procedure (PPMP)
CLIA Certificates. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
26.2.3.1 Waiver Certificate . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
26.2.3.2 PPMP Certificates . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
26.3 Reimbursement . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
26.3.1 Texas Health Steps (THSteps) Outpatient Laboratory Services . . . . . . . . . . . .
26.4 Benefits and Limitations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
26.4.1 Reference Labs and Lab Handling Fees . . . . . . . . . . . . . . . . . . . . . . . . . . . .
26.4.2 Repeated Procedures . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
26.4.2.1 Modifier 91 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
26.4.2.2 Modifier 76 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
26.4.3 Laboratory Paneling . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
26.4.3.1 Chemistry Tests . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
26.4.3.2 Urinalysis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
26.4.3.3 CBC . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
26.4.4 Organ or Disease Panels . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
26.4.5 Ferritin and Iron Studies . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
26.4.6 Laboratory Services for Clients on Dialysis . . . . . . . . . . . . . . . . . . . . . . . . . .
26.4.7 Transfusion Medicine . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
26.5 Claims Information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
26.5.1 Electronic Filing for Laboratory Providers . . . . . . . . . . . . . . . . . . . . . . . . . . . .
26.5.2 Claim Filing Resources . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
CPT only copyright 2008 American Medical Association. All rights reserved.
26-2
26-2
26-2
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26-3
26-3
26-3
26-3
26-4
26-4
26-4
26-4
26-5
26-5
26-5
26-6
26-6
26-7
26-8
26-8
26-8
26-8
26-8
Section 26
26.1 Enrollment
To enroll in Texas Medicaid, the independent
(freestanding) laboratory must:
• Be independent from a physician’s office or hospital.
• Meet the staff, equipment, and testing capability
standards for certification by HHSC.
• Have Medicare certification.
• Submit a current copy of the medical director’s
physician license, if the lab has physician involvement.
Important: All providers are required to read and comply
with Section 1, Provider Enrollment and Responsibilities.
In addition to required compliance with all requirements
specific to Medicaid, it is a violation of the Medicaid
Program rules when a provider fails to provide health-care
services or items to Medicaid clients in accordance with
accepted medical community standards and standards
that govern occupations, as explained in Title 1 Texas
Administrative Code (TAC) §371.1617(a)(6)(A). Accordingly, in addition to being subject to sanctions for failure
to comply with the requirements that are specific to
Medicaid, providers can also be subject to Medicaid
sanctions for failure, at all times, to deliver health-care
items and services to Medicaid clients in full accordance
with all applicable licensure and certification requirements
including, without limitation, those related to documentation and record maintenance.
Refer to: “Provider Enrollment” on page 1-3 for more
information about enrollment procedures.
“Medicaid Managed Care” on page 7-5 for more
information.
26.2 Clinical Laboratory Improvement
Amendments (CLIA)
26.2.1 CLIA Requirements
To be eligible for reimbursement by Medicare and
Medicaid, all providers performing laboratory tests must:
TMHP monitors claims submitted by clinical laboratories
for CLIA numbers. If there is not a CLIA number on file with
TMHP, claims for laboratory services will be denied.
26.2.2 CLIA Regulations
CMS implemented CLIA rules and regulations. The CLIA
regulations were published in the February 28, 1992,
Federal Register and have been amended several times
since. The regulations are found at Title 42 Code of
Federal Regulations, Part 493.
The CLIA rules and regulations are available on the CMS
website at www.cms.gov.
CLIA regulations set standards designed to improve
quality in all laboratory testing and include specifications
for quality control (QC), quality assurance (QA), patient
test management, personnel, and proficiency testing.
These regulations concern all laboratory testing used to
assess human health or to diagnose, prevent, or treat
disease. Under CLIA 88, all clinical laboratories (including
those located in physicians’ offices), regardless of
location, size, or type of laboratory, must meet standards
based on the complexity of the test(s) they perform.
26.2.3 Limits of Waiver and PhysicianPerformed Microscopy Procedure (PPMP)
CLIA Certificates
CLIA certificates may limit the holder to performing only
certain tests. Medicaid bills must accurately reflect only
services authorized by the CLIA program and no other
procedures. Two types of certificates limit holders to only
certain test procedures: Waiver and PPMP certificates.
26.2.3.1 Waiver Certificate
Providers holding waiver CLIA certificates are authorized
to perform only the tests in the following table. These
tests were granted waiver status under CLIA and were
updated beginning September 27, 2002. The QW modifier
is a CLIA requirement for specific codes based on their
complexity and must be included or claims will be denied.
• Pay a fee to the Centers for Medicare & Medicaid
Services (CMS).
Procedure Codes
• Contact HHSC at 1-512-834-6650 to receive a CLIA
registration and/or certification number. Providers can
submit CLIA applications to the following address:
80047-QW
80048-QW
80051-QW
80053-QW
80061-QW
80101-QW
81002
81003-QW
81025
82010-QW
82044-QW
82055-QW
82120-QW
82270
82271-QW
82272-QW
82274-QW
82465-QW
82523-QW
82570-QW
82679-QW
82947-QW
82950-QW
82951-QW
82952-QW
82985-QW
83001-QW
83002-QW
83026
83036-QW
83037-QW
83518-QW
83605-QW
83718-QW
83721-QW
83880-QW
83986-QW
84450-QW
84460-QW
84478-QW
84520-QW
84703-QW
85013
85014-QW
85018-QW
85576-QW
85610-QW
85651
Health Facility Licensing and Certification Division
HHSC
1100 West 49th Street
Austin, TX 78756
• Notify TMHP of the assigned CLIA number at the
following address:
Texas Medicaid & Healthcare Partnership
Provider Enrollment
PO Box 200795
Austin, TX 78720-0795
26–2
CPT only copyright 2008 American Medical Association. All rights reserved.
Independent Laboratory
Procedure Codes
86294-QW
86308-QW
86318-QW
86618-QW
86701-QW
86703-QW
87077-QW
87210-QW
87449-QW
87804-QW
87880-QW
G0107
26.2.3.2 PPMP Certificates
Holders of PPMP certificates are authorized to perform all
the procedures listed for waiver certificates and the
following tests:
Procedure Codes
81000
81001
81015
81020
Q0111
Q0112
Q0113
Q0115
Except for Pap smears, other required THSteps laboratory
work that can be mailed at ambient temperature must be
sent to the DSHS Laboratory Services Section using the
business reply label provided to the following address:
Laboratory Services Section, MC 1947
Department of State Health Services
PO Box 149163
Austin, TX 78714-9803
THSteps laboratory work that requires overnight shipping
on cold packs through a courier service must be sent to
the DSHS Laboratory Services Section at the following
address:
89190
Laboratory Services Section, MC 1947
Department of State Health Services
1100 West 49th Street
Austin, TX 78756-3199
1-512-458--7318
Fax: 1-512-458-7294
Toll-free: 1-888-963-7111 ext. 7318
26.3 Reimbursement
The Medicaid rates for independent laboratories are calculated in accordance with 1 TAC §355.8081 and
§355.8610, and the Deficit Reduction Act (DEFRA) of
1984. By federal law, Medicaid payments for clinical
laboratory services cannot exceed the Medicare payment
for that service.
As the result of the Tax Equity and Fiscal Responsibility Act
(TEFRA) of 1982, independent laboratories are not directly
reimbursed by Medicaid when providing tests to clients
registered as hospital inpatients. Reimbursement must
be obtained from the hospital.
These services cannot be billed to the client.
Refer to: “Reimbursement Methodology” on page 2-2 for
more information about reimbursement.
Pap smear specimens must be sent to the following
address:
Women’s Health Laboratories
2303 SE Military Drive, Suite 1
San Antonio, TX 78223
Customer Service: 1-888-440-5002 or 1-210-531-4596
Fax: 1-210-531-4506
Claims for tests listed in the following table submitted by
a THSteps medical provider or an outside laboratory for
the same date of service as a THSteps medical check up
will be denied and are subject to retrospective review and
recoupment of inappropriate payments.
Laboratory Test Procedure Codes
83020
83021
83655
85013
85014
26.3.1 Texas Health Steps (THSteps)
Outpatient Laboratory Services
85018
86403
86592
86689
86701
The Medicaid service, Early and Periodic Screening,
Diagnosis, and Treatment (EPSDT), is known in Texas as
Texas Health Steps (THSteps).
87490
87590
88141
88142
88143
88147
88148
88150
88152
88153
88154
88164
88165
88166
88167
88174
88175
Refer to: “Eligibility for a Medical Checkup” on
page 43-7.
All required THSteps laboratory work, except for screening
related to type 2 diabetes and hyperlipidemia, is to be
performed by the Department of State Health Services
(DSHS) Laboratory Services Section. DSHS makes
laboratory supplies and services available for free to all
enrolled THSteps medical providers for THSteps clients.
THSteps laboratory services provided by a private
laboratory will not be reimbursed. The DSHS Laboratory
Services Section is reimbursed at its cost for performing
these tests.
Texas Health Steps (THSteps) medical providers may
choose the laboratory to which they send THSteps
laboratory specimens for blood test screening for hyperlipidemia or Type 2 diabetes.
Laboratories that bill for these procedure codes on the
same date of service as a medical check up visit can be
reimbursed separately.
Providers that obtain and process these specimens inhouse are not reimbursed separately.
26.4 Benefits and Limitations
Texas Medicaid only covers professional and technical
services that an independent laboratory is certified by
Medicare to perform.
CPT only copyright 2008 American Medical Association. All rights reserved.
26–3
26
Section 26
Medicaid pays up to the amount allowed for the total
component for the same procedure, same client, same
date of service, any provider.
• Providers that perform the technical service and interpretation must bill for the total component.
• Providers that perform only the technical service must
bill for the technical component.
• Providers that perform only the interpretation must bill
for the interpretation component.
Claims filed in excess of the amount allowed for the total
component for the same procedure, same dates of
service, same client, any provider, are denied. Claims are
paid based on the order in which they are received. For
example, if a claim is received for the total component and
TMHP has already made payment for the technical or interpretation component for the same procedure, same dates
of service, same client, any provider, the claim for the
total component will be denied as previously paid to
another provider. The same is true if a total component
has already been paid and claims are received for the
individual components.
26.4.1 Reference Labs and Lab Handling
Fees
An independent laboratory that forwards a specimen to
another laboratory without performing any tests on that
specimen may not bill for any laboratory tests. An
independent laboratory may only bill Medicaid for tests
referred to another laboratory (independent or hospital) if
it performs at least one test (that it is Medicare-certified
to perform) and forwards a portion of the same specimen
to another laboratory (reference laboratory) to have one or
more tests performed.
In this instance, the referring laboratory may bill for tests
it has performed and all tests it is to perform on the
specimen. When billing, the Yes box in Block 20 of the
CMS-1500 claim form must be marked, the name,
address, and ZIP code of the reference lab to where the
specimens have been forwarded must be indicated in
Block 32, and the Texas Provider Identifier (TPI) and
National Provider Identifier (NPI) of the reference lab must
be indicated in Block 24-J next to each procedure to be
performed by the reference lab. The TPI goes in the
shaded area of the block. The NPI goes in the unshaded
area of the block.
Only one handling fee may be charged per day, per client,
unless specimens are sent to two or more different laboratories; this must be documented on the claim.
An independent laboratory that forwards a specimen to
another laboratory (independent or hospital) may bill a
handling fee (procedure code 99001) for collecting and
forwarding the specimen to the other laboratory if the
specimen is collected by routine venipuncture or catheterization. Routine venipunctures or finger, heel, and ear
sticks for collection of specimen(s) (procedure code
36415) are not benefits of Medicaid. Family planning
agencies must use procedure code 99000 with modifier
FP to bill their laboratory handling charges for laboratory
26–4
specimens sent out. As with the procedure code 99000,
only one handling fee may be charged for each laboratory
to the agency that sends specimens, regardless of the
number of specimens taken.
When family planning test specimens such as Pap smears
are collected, providers must direct the laboratory to
indicate the claim for the test is to be billed as a family
planning service.
26.4.2 Repeated Procedures
26.4.2.1 Modifier 91
Modifier 91 should be used for repeat clinical diagnostic
tests as follows:
• Modifier 91 must not be used when billing the initial
procedure. It must be used to indicate the repeated
procedure.
• If more than two services are billed on the same day by
the same provider, regardless of the use of
modifier 91, the claim or detail is denied.
• If a repeated procedure performed by the same provider
on the same day is billed without modifier 91, it is
denied as a duplicate procedure.
• If a claim is denied for a quantity more than two or as
a duplicate procedure, the times of these procedures
and services must be documented on appeal.
• Modifier 91 is not required and must not be used when
billing multiple quantities of a supply.
For dates of service on or after April 3, 1998, certain
procedure codes have been removed from modifier 91
auditing. These are procedure codes that have been
identified as routinely being performed at the same time,
more than twice per day for each antigen (e.g., agglutinins, febrile [e.g., Brucella, Francisella, Murine typhus,
Q fever, Rocky Mountain spotted fever, scrub typhus],
each antigen). Providers may still appeal claims that have
been denied for documentation of time. Most procedure
codes initially requiring modifier 91 will continue to be
audited for modifier 91.
When appealing claims with modifier 91 for repeat procedures, providers must separate the details. One detail
should be appealed without the modifier and one detail
with the modifier, including documentation of times for
each repeated procedure.
26.4.2.2 Modifier 76
Modifier 76 is limited as follows:
• Modifier 76 must not be used when billing the initial
procedure. It must be used to indicate the repeated
procedure.
• If more than two services are billed on the same day by
the same provider, regardless of the use of
modifier 76, the claim or detail is denied.
CPT only copyright 2008 American Medical Association. All rights reserved.
Independent Laboratory
• If a repeated procedure performed by the same provider
on the same day is billed without modifier 76, it is
denied as a duplicate procedure.
must be combined and billed as a CBC/panel. Resubmit
with signed claim copy, R&S report copy, and appropriate
code (85025 and 85027).”
• If a claim is denied for a quantity more than two or as
a duplicate procedure, the times of these procedures/services must be documented on appeal.
The chemistry tests in the following table must be billed
individually unless a complete panel is performed:
• Modifier 76 is not required and must not be used when
billing multiple quantities of a supply.
Certain procedure codes have been removed from
modifier 76 auditing for dates of service on or after
April 3, 1998. These procedure codes have been
identified as routinely being performed at the same time,
more than twice per day for each antigen (e.g., agglutinins, febrile [e.g., Brucella, Francisella, Murine typhus,
Q fever, Rocky Mountain spotted fever, scrub typhus],
each antigen). Providers may still appeal claims that have
been denied for documentation of time. Most procedure
codes initially requiring modifier 76 will continue to be
audited for modifier 76.
When appealing claims with modifier 76 for repeat procedures, providers must separate the details. One detail
should be appealed without the modifier and one detail
with the modifier, including documentation of times for
each repeated procedure.
26.4.3 Laboratory Paneling
The reimbursement for the complete panel procedure
code represents the total payment for all laboratory
services covered under that panel. The Medicaid
allowable fee for the individual components of the
complete lab panel does not exceed the fee for the
complete lab panel. The provider is reimbursed the lesser
of the combined fees for the two or more laboratory
services delivered or the single panel fee.
When all of the components of the panel are performed,
the complete panel procedure code must be billed. When
only two or more components of the panel are performed,
the individual procedure codes for each laboratory test
performed may be billed.
Refer to: “Laboratory Services” on page 36-63
26.4.3.1 Chemistry Tests
Medicare policy pertaining to laboratory paneling procedures was implemented by Medicaid. Organ and disease
panel codes 80048, 80051, and 80053 must be used
instead of the general multichannel automated panel
codes.
Procedure code 84078 is considered a component of the
multiple chemistry panels. Procedure code 85595 is
considered a component of any hemogram with a platelet
panel. Hemogram or CBC with platelet panel codes 85025
to 85027 must be billed when two or more components of
a CBC and a platelet count are performed. When two or
more components of a CBC and a platelet count are billed
separately on the same day, all components are denied
with explanation of benefits (EOB) 00559, “These tests
CPT only copyright 2008 American Medical Association. All rights reserved.
Procedure Codes
82040
82150
82247
82248
82310
82373
82374
82435
82465
82550
82565
82945
82947
82948
82977
83090
83615
83663
83664
83690
83735
83921
84075
84078
84100
84132
84152
84155
84160
84295
84450
84460
84478
84520
84550
84591
26.4.3.2 Urinalysis
Procedure codes 81000, 81001, 81002, 81003, 81005,
81015, 81020, 84578, 84580, and 84583 are only
payable as a total component (type of service 5) and are
not payable in the inpatient hospital setting.
Procedure code 84578 may be reimbursed on the same
date of service as a urinalysis with or without microscopy
for procedure codes 81000, 81001, 81002, 81003,
81005, and 81020.
Procedure code 84578 is denied as part of another
service when submitted for the same date of service as
procedure code 84580 or 84583.
Procedure codes 81002 and 81015 are denied as part of
another service when submitted for reimbursement with
procedure code 81000 for the same date of service by the
same provider.
Procedure codes 81002, 81003, 81007, and 81015 are
denied as part of another service when submitted for
reimbursement with procedure code 81001 for the same
date of service by the same provider.
Procedure code 81000 is denied as part of another
service when submitted for reimbursement with procedure
code 81003, 81005, or 81020 for the same date of
service by the same provider.
Procedure code 82044 is denied as part of another
service when submitted for reimbursement with procedure
code 81015 for the same date of service by the same
provider.
When related urinalysis procedure codes are billed for the
same date of service by the same provider, the first
procedure code is reimbursed and all other procedure
codes are denied. An explanation of benefits (EOB) code
will appear on the Remittance and Status (R&S) report
indicating the claim should be resubmitted with a copy of
the R&S report and an appropriate urinalysis procedure
code that combines the related components.
26–5
26
Section 26
26.4.3.3 CBC
Texas Medicaid considers a baseline CBC appropriate for
the evaluation and management of existing and
suspected disease processes. CBCs should be individualized and based on client history, clinical indications, or
proposed therapy and will not be reimbursed for screening
purposes.
The following procedure codes will be denied as part of
another service when billed with procedure code 85025
for the same date of service by the same provider:
Procedure Codes
85004
85007
85008
85009
85013
85014
85018
85027
85032
85041
85048
85049
Procedure code 85004 will be denied as part of another
service when billed with procedure code 85007, 85009,
85025, or 85027 for the same date of service by the
same provider.
Procedure code 85007 will be denied as part of another
service when billed with procedure code 85025 for the
same date of service by the same provider.
Procedure code 85008 will be denied as part of another
service when billed with procedure codes for the same
date of service by the same provider 85004, 85025,
85027, 85032, 85048, or 85049.
Procedure code 85009 will be denied as part of another
service when billed with procedure code 85025 for the
same date of service by the same provider.
Procedure code 85013, 85014, or 85018 will be denied
as part of another service when billed with procedure code
85025 or 85027 for the same date of service by the same
provider.
Procedure code 85027 will be denied as part of another
service when billed with procedure code 85025.
The components of a CBC are listed in the following table:
Procedure Codes
85004
85007
85008
85009
85013
85014
85018
85041
85048
85049
Procedure code 85049 may be reimbursed separately If
this procedure code is billed for the same date of service
as procedure codes 85025 or 85027, it will deny as part
of another service.
Reticulocyte procedure codes 85044, 85045, and 85046
may be reimbursed in addition to a CBC.
26.4.4 Organ or Disease Panels
Organ panels are specific laboratory studies that have
been combined under a problem-oriented classification as
an approach to diagnosis. The following list of panels
includes all components that must be included to report
the panel code.
Individual laboratory studies considered a part of a
specific panel are denied when billed on the same day as
the panel code by the same provider.
The panels include the following procedure codes:
80047 - Panel must include:
82330
82374
82435
82565
82947
84132
84295
84520
80048 - Panel must include:
82310
82374
82435
82565
82947
84132
84295
84520
80050 - Panel must include:
80053
84443
PLUS
Procedure code 85032 will be denied as part of another
service when billed with procedure code 85025, 85027,
85041, 85048, or 85049.
85025
OR
85027 and either 85004, 85007, or 85009
Procedure codes 85041 will be denied as part of another
service when billed with procedure code 85025 or 85027.
80051 - Panel must include:
Procedure codes 85044 will be denied as part of another
service when billed with procedure code 85045 or 85046.
Procedure code 85045 will be denied as part of another
service when billed with procedure code 85046.
82374
82435
84132
84295
80053 - Panel must include:
82040
82247
82310
82374
Procedure codes 85048 will be denied as part of another
service when billed with procedure code 85025 or 85027.
82435
82565
82947
84075
84132
84155
84295
84450
Procedure code 85049 will be denied as part of another
service when billed with procedure codes 85025 or
85027.
84460
84520
A CBC is a comprehensive service that includes
components.
26–6
CPT only copyright 2008 American Medical Association. All rights reserved.
Independent Laboratory
80055 - Panel must include:
Diagnosis Codes
86592
86762
86850
2828
2829
2839
2850
28521
86900
86901
87340
28522
28529
2859
33399
4254
PLUS
4260
42610
42611
42612
42613
85025
OR
85027 and either 85004, 85007, or 85009
4262
4263
4264
42650
42651
42652
42653
42654
4266
4267
42681
42682
42689
4269
4270
80061 - Panel must include:
4271
4272
42731
42732
42741
82465
42742
42760
42761
42769
42781
42789
4279
4280
4281
42820
42821
42822
42823
42831
42832
42833
42840
42841
42842
42843
4289
4481
57140
57141
57142
57149
5715
5718
5719
5738
5739
60784
6083
6260
6261
70400
70900
70909
7099
7130
71500
71504
71509
71510
71511
71512
71513
71514
71515
71516
71517
71518
71520
71521
71522
71523
71524
71525
71526
71527
71528
71530
71531
71532
71533
71534
71535
71536
71537
71538
71580
71589
71590
71591
71592
71593
71594
71595
71596
71597
71598
71640
71641
71642
71643
71644
71645
71646
71647
71648
71649
71650
71651
71652
71653
71654
71655
71656
71657
71658
71659
71660
71661
71662
71663
71664
71665
71666
71667
71680
71681
71682
71683
71684
71685
71686
71687
71688
71689
71690
71691
71692
71693
71694
71695
71696
71697
71698
71699
7891
7892
78951
78959
7904
7906
83718
84478
80069 - Panel must include:
82040
82310
82374
82435
82565
82947
84100
84132
84295
84520
80074 - Panel must include:
86705
86709
86803
87340
80076 - Panel must include:
82040
82247
82248
84155
84450
84460
84075
26.4.5 Ferritin and Iron Studies
Procedure codes 82728, 83540, 83550, 84466, and
85536 are a benefit when medically necessary and are
payable in the office, inpatient and outpatient hospital,
and independent laboratory setting for the following
diagnoses:
Diagnosis Codes
23871
23872
23873
23874
23875
23876
23877
23879
24900
24901
24910
24911
24920
24921
24930
24931
24940
24941
24950
24951
24960
24961
24970
24971
24980
24981
24990
24991
25000
25001
25002
25003
25010
25011
25012
25013
25020
25021
25022
25023
25030
25031
25032
25033
25040
25041
25042
25043
25050
25051
25052
25053
25060
25061
25062
25063
25070
25071
25072
25073
Diagnosis Codes
25080
25081
25082
25083
25090
5360
5728
5793
5798
5799
25091
25092
25093
2570
2572
5851
5852
5853
5854
5855
2578
2579
2750
2800
2801
5856
5859
586
64820
64821
2808
2809
2810
2811
2812
64822
64823
64824
V560
V5631
2813
2814
2818
2819
28241
V5632
V568
28242
28249
28260
28261
28262
28263
28264
28268
28269
2827
CPT only copyright 2008 American Medical Association. All rights reserved.
The following diagnosis codes will no longer be
reimbursed for procedure codes 82728, 83540, 83550,
84466, and 85536:
26–7
26
Section 26
Procedure codes 82728, 83540, 83550, 84466, and
85536 may be reimbursed on the same day for the same
provider, except when 84466 and 83550 are billed on the
same day. If procedure codes 84466 and 83550 are
billed on the same day, procedure code 84466 may be
reimbursed and procedure code 83550 will be denied.
Providers must use the appropriate modifier when billing
these procedure codes more than once on the same day
by the same provider.
Iron studies may be reimbursed only to physicians,
independent laboratories, Federally Qualified Health
Centers (FQHCs), inpatient and outpatient hospitals,
nephrologists, renal dialysis facilities, and rural health
clinics. Type of service I is no longer payable for procedure
codes 83540, 83550, and 84466.
26.4.6 Laboratory Services for Clients on
Dialysis
Texas Medicaid provides reimbursement for laboratory
services performed for clients on dialysis.
Charges for routine laboratory tests performed according
to the established frequencies are included in the
facility’s dialysis charge billed to Medicaid regardless of
where the tests were performed. Routine laboratory
services performed by an outside laboratory are billed to
the facility.
Nonroutine laboratory services for clients dialyzing in a
facility and all lab work for clients on continuous
ambulatory peritoneal dialysis (CAPD) may be billed
separately from the dialysis charge. These services and
recommended frequencies are listed in “Laboratory and
Radiology Services” on page 40-5.
26.4.7 Transfusion Medicine
Procedure code 86890 is denied when billed by any
provider for the same client for dates of service in excess
of two times within four days. The use of modifier 76 does
not prevent claim denials. Documentation may be
submitted on appeal that supports the medical necessity
and appropriateness of more than two predeposited autologous donations in four days.
26.5 Claims Information
When family planning test specimens such as Pap smears
are collected, providers must direct the laboratory to
indicate the claim for the test is to be billed as a family
planning service using diagnosis code V2509.
When completing a CMS-1500 claim form, all required
information must be included on the claim, as information
is not keyed from attachments. Superbills, or itemized
statements, are not accepted as claim supplements.
Refer to: “TMHP Electronic Data Interchange (EDI)” on
page 3-1 for information on electronic claims
submissions.
“Claims Filing” on page 5-1 for general information about claims filing.
“CMS-1500 Claim Filing Instructions” on
page 5-26. Blocks that are not referenced are
not required for processing by TMHP and may be
left blank.
26.5.1 Electronic Filing for Laboratory
Providers
Referring provider information is always required on
laboratory claims. Failure to submit this data will result in
a claim rejection on the TMHP Electronic Data Interchange
(EDI).
When the place of service is 6 and the billing provider
identifier belongs to a laboratory, there is no need to
submit the same provider identifier in the facility ID field.
This notation causes the claim to suspend processing
unnecessarily, and may cause a delay in the disposition
of the claim.
For questions about the electronic fields, contact the
commercial software vendor or the TMHP EDI Help Desk
at 1-888-863-3638.
26.5.2 Claim Filing Resources
Refer to the following sections and/or forms when filing
claims:
Resource
Page Number
Automated Inquiry System (AIS)
xiii
TMHP Electronic Data Interchange
(EDI)
3-1
CMS-1500 Claim Filing Instructions
5-26
TMHP Electronic Claims Submission
5-15
Communication Guide
A-1
Independent Laboratory Claim
Example
D-19
Acronym Dictionary
F-1
A National Provider Identifier (NPI) is required for all
claims. In addition, for paper claims, the Texas Provider
Identifier (TPI) is required for the billing and performing
provider only. NPI-only is required for all other fields.
Providers must submit independent laboratory services to
TMHP in an approved electronic format or on a CMS-1500
paper claim form. Providers must purchase CMS-1500
claim forms from the vendor of their choice. TMHP does
not supply the forms.
26–8
CPT only copyright 2008 American Medical Association. All rights reserved.