CurrentBlue Cross Blue Shield - Rhode IslandPolicy N/A

Date of Service (DOS) for laboratory specimen payment

Administrative policy governing how Blue Cross Blue Shield of Rhode Island determines the date of service for laboratory tests based on specimen collection, storage, and special exceptions (including chemotherapy sensitivity tests). Affects providers submitting lab claims and facility billing related to hospital-collected specimens.

Policy Summary

PayerBlue Cross Blue Shield - Rhode Island

PolicyDate of Service (DOS) for laboratory specimen payment

Policy CodePolicy N/A

Change TypeNo material change

Effective Date06/16/2009

Next Review DateN/A

Key ActionNo prior authorization required for services covered under this policy.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

30Archived specimen threshold (days)

14Order timing after discharge (days)

CMS adherenceGuideline alignment

Not applicablePrior authorization

Date of Service Determination — Rules and Exceptions

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DOS determination criteria

General rule and exceptions for determining the Date of Service (DOS) for laboratory tests:

Default DOS is the date the specimen was collected.

If specimen collection spans two calendar days, DOS is the date the collection ended.

Exception: Stored specimen ≤ 30 days

Specimen was collected while the patient was undergoing a hospital surgical procedure.
The test was ordered by the patient's physician at least 14 days after the date of the patient's discharge from the hospital.
It would be medically inappropriate to have collected the sample other than during the hospital procedure for which the patient was admitted.
The test was reasonable and medically necessary for treatment of an illness.
The results do not guide treatment provided during the hospital stay.

Exception: Stored specimen > 30 days (archived): If a specimen was stored for more than 30 calendar days before testing (considered archived), the DOS must be the date the specimen was obtained from storage.

Exception: Chemotherapy sensitivity tests on live tissue

Specimen was collected while the patient was undergoing a hospital surgical procedure.
The decision regarding the chemotherapeutic agents to test was made at least 14 days after discharge.
It would be medically inappropriate to have collected the sample other than during the hospital procedure for which the patient was admitted.
The test was reasonable and medically necessary for treatment of an illness.
The results do not guide treatment provided during the hospital stay.

Commercial plan note: For commercial members, if the decision to send out the specimen is made at least 14 days after discharge AND the specimen arrives at the reference lab more than 30 days after discharge, the specimen may be reported as the date it is received (treated as outside the hospital payment). If ordered 13 days or less after discharge or received 30 days or less after the procedure, the facility retains the obligation.

BCBSRI follows CMS guidelines regarding the date of service of laboratory specimens.

Coding, Time Thresholds, and Order Timing

Codingmixed

No codes listed

Archived specimen threshold

Archived specimen thresholdSpecimen stored more than 30 calendar days is considered archived; DOS must be the date the specimen was obtained from storage.

Stored ≤30 days — exception conditionsIf specimen stored 30 days or less, DOS may be the test date only when all of the following apply: collected during a hospital surgical procedure; test ordered at least 14 days after patient discharge; medically inappropriate to collect sample otherwise; test reasonable and medically necessary; results do not guide treatment provided during the hospital stay.

Default DOS ruleThe DOS of the test shall be the date the specimen was collected, or if collection spans two calendar days, the date the collection ended.

Physician order timing after discharge for exception

Physician order timing for exceptionThe physician must order the test at least 14 days after the patient’s hospital discharge for the stored-specimen exception to apply.

Decision to send specimen (commercial note)For commercial members, if decision to send out the specimen is made at least 14 days after discharge and specimen arrives >30 days after discharge, BCBSRI may allow reporting the date received.

Related DOS condition for chemotherapy sensitivity testsFor chemotherapy sensitivity tests, the decision regarding agents to test must be made at least 14 days after discharge for the test date to be the DOS.

Key Definitions

Chemotherapy sensitivity test

DefinitionA chemotherapy sensitivity test is a test that uses a fresh tissue sample to test the sensitivity of tumor cells to various chemotherapeutic agents (as identified by CMS program instructions).

Applicability to DOS exceptionsFor chemotherapy sensitivity tests performed on live tissue, DOS may be the test date only if specimen collected during a hospital surgical procedure; decision on agents made ≥14 days after discharge; medically inappropriate to collect otherwise; test is reasonable and medically necessary; and results do not guide treatment during the hospital stay.

CMS identificationCMS identifies chemotherapy sensitivity tests through program instructions issued to Medicare contractors.