CurrentUnitedHealthcarePolicy N/A

Laboratory reimbursement methodology and duplicate service rules

Defines UnitedHealthcare Community Plan Medicaid reimbursement rules for laboratory services billed on CMS-1500 (and electronic equivalent), including panels, components, place/date of service, duplicate submissions, modifiers, and documentation requirements affecting physicians, QHPs, laboratories and facilities.

Policy Summary

PayerUnitedHealthcare

PolicyLaboratory reimbursement methodology and duplicate service rules

Policy CodePolicy N/A

Change TypeNo material change

Effective DateN/A

Next Review DateN/A

Key ActionOrder must be from the treating physician or other qualified health care professional and documentation must show the specific tests ordered.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

CMS-1500claim form this policy applies to

11panel CPT codes listed

Modifier 90reference lab rule

91repeat test modifier

Laboratory Coverage Criteria

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Laboratory reimbursement criteria

Reimbursement and duplicate submission rules

Only one laboratory service is reimbursable when Duplicate Laboratory Services are submitted from the Same Group Physician or Other QHP.

Separate consideration for repeats: Separate consideration will be given to repeat procedures performed the same day by the Same Group Physician or Other QHP when reported with modifier 91.

Only one laboratory provider will be reimbursed when multiple individuals report Duplicate Laboratory Services (includes physicians, Other QHPs, Independent Laboratories, Reference Laboratories, Referring Laboratories, and pathologists).

If a Reference Laboratory and a Non-Reference Laboratory submit Duplicate Laboratory Services, only the Reference Laboratory service is reimbursable.

Laboratory services billed with modifier 90 by a Referring Laboratory are reimbursable only if a duplicate claim has not been received from an Independent or Reference Laboratory; duplicate services are not reimbursable unless one laboratory appends modifier 91.

If a pathologist and a Physician Office Laboratory submit Duplicate Laboratory Services, only the pathologist's service is reimbursable unless the Physician Office Laboratory appends modifier 91 to the codes submitted.

Manual and automated laboratory services submitted with a facility Place of Service (POS 19,21,22,23,26,34,51,52,55,56,57,61) are not reimbursable to independent/reference/non-reference labs and are reimbursable to the facility; exception for specialized molecular/genomic/reproductive tests when the facility is not equipped to perform them.

Individual laboratory codes that together make up a laboratory panel will be denied; the provider must submit the comprehensive panel code.

Laboratory panel criteria

Panel billing criteria and denial rules

Individual component laboratory codes that together comprise a defined panel will be denied; provider must submit the comprehensive panel code unless fewer than all components are submitted.

Effective for claims with dates of service on or after April 18, 2020: if fewer than all component codes that make up a panel are submitted, the component codes will be considered individually for reimbursement; claims will be denied when all components found on the lab panel list are submitted.

Surgical pathology criteria

Surgical pathology billing criteria

Two or more specimens separately identified from the same patient are each assigned an individual code; pathology specimens from the same anatomic site reported with the same CPT code may be reported on one line with multiple units.

Duplicate pathology specimens reported with the same Surgical Pathology CPT code must be reported with modifier 59, XE, XP, XS, XU or 91 to receive separate consideration.

Modifiers appropriate to indicate distinct procedural services for duplicate pathology specimens include 59, XE, XP, XS, XU and 91.

Laboratory coverage criteria and billing rules

Reimbursement and bundling criteria

Only one collection fee for each specimen type per patient encounter is reimbursed; a collection fee will not be reimbursed to anyone who did not extract the specimen.

Venous blood collection by venipuncture (CPT 36415) reimbursed once per patient per date of service by the Same Individual Physician or Other QHP; CPT 36416 (capillary collection) bundles into 36415 when submitted together and is considered integral to an E/M when performed by the same provider on the same date.

Collection from implantable venous access devices (CPT 36591/36592) is bundled into services with CMS NPFS status indicator A, R or T provided the same date by the Same Individual Physician or Other QHP; when 36591 and 36592 are submitted together, only 36592 is eligible for reimbursement.

CPT codes 80503-80506 and 88321-88325 are reimbursable only to Reference Laboratories and providers whose primary specialty is pathology or dermatology; these codes are considered included in an E/M service when billed the same date by the same provider and are not separately reimbursable.

Codes, Panels and Modifiers

ModifiersModifier

59	Distinct procedural service
90	Reference (outside) laboratory
91	Repeat clinical diagnostic laboratory test
92	Alternative laboratory platform testing
XE	Separate Encounter - A Service That Is Distinct Because It Occurred During A Separate Encounter
XP	Separate Practitioner - A Service That Is Distinct Because It Was Performed By A Different Practitioner
XS	Separate Structure - A Service That Is Distinct Because It Was Performed On A Separate Organ/Structure
XU	Unusual Non-Overlapping Service

Organ/Disease-Oriented Panel CPT CodesCPTCovered

80047	Comprehensive metabolic panel configurations (components listed in policy)
80048	Basic metabolic panel configurations (components listed in policy)
80050	General health panel
80051	Additional configuration for 80047
80053	Comprehensive metabolic profile (multiple configurations)
80055	Infectious disease/hepatic function panel (components include 86592, 86762, 86850, 86900, 86901, 87340 and CBC options)
80061	Lipid panel (components include 82465, 83718, 84478)
80069	Hepatic function panel (configurations include components and/or panel 80048)
80074	Infectious disease profile (components include 86705, 86709, 86803, 87340)
80076	Thyroid panel (components include 82040, 82247, 82248, 84075, 84155, 84450, 84460)

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Surgical Pathology CPT CodesCPTCovered

88300-88309

Surgical pathology; gross and microscopic examination and pathologic diagnosis

Panel 80081 / 80055 relationshipmixedCovered

80081	Includes components and CBC options; Configuration 2 may include panel 80055 plus 87389
80055	Panel 80055 or 80081 takes precedence when 87340 is a component of multiple panels

Surgical Pathology — Duplicate SpecimensCPTCovered

88300-88309

Duplicate pathology specimens reported with the same code must include modifier 59, XE, XP, XS, XU or 91 for separate consideration

Venipuncture and Specimen CollectionCPTCovered

36415	Venous blood draw; reimbursed once per patient per date of service when reported by the Same Individual Physician or Other QHP
36416	Capillary blood collection; bundled into 36415 or E/M when performed same date by same provider—only reimbursed separately when eligible per policy
36591	Collection from implantable venous access device; bundling rules apply
36592	Collection from established catheter; bundling rules apply
S9529	Non-reimbursable — place-of-service code; represented by 36415 instead

Laboratory handling and conveyance — non-reimbursablemixedNot Covered

99000	Handling and conveyance of specimen — included in overall management, not separately reimbursed
99001	Handling and conveyance additional special handling — included in overall management, not separately reimbursed
H0048	Alcohol and/or drug services; bio-chemical, specimen collection and handling — included in overall management, not separately reimbursed

Drug Assay CodesCPTNot Covered

80320-80377

Drug assay CPT codes considered non-reimbursable; may be reported under appropriate HCPCS when applicable

Key coding rules and operational dates

Panel vs component reportingIndividual component codes that together form a panel will be denied; provider must submit the comprehensive panel code

Effective date for component handlingFor claims with dates of service on or after April 18, 2020, if fewer than all component codes are submitted, components will be considered individually; claims will be denied when all components found on the lab panel list are submitted

Duplicate laboratory service ruleIdentical or equivalent component codes submitted for the same patient on the same date will be denied unless a repeat or separating modifier (e.g., 59, XE, XP, XS, XU, 91) is appended as allowed

Billing and Documentation Actions for Providers

Documentation Required

Order and documentation requirement

Orders for diagnostic laboratory tests must be from the treating physician or other qualified health care professional and the medical record must clearly indicate the specific test(s) to be performed. Acceptable documentation includes a signed order or requisition listing the specific tests, or an unsigned order/requisition listing the specific tests plus an authenticated medical record supporting the physician's intent to order the tests; electronic requisitions are acceptable when receipt can be demonstrated. The medical record must also include a copy of the test results.

Signed order or requisition listing specific test(s).
Unsigned order/requisition plus authenticated medical record (e.g., progress/office notes) supporting intent to order.
Electronic requisition acceptable if laboratory can demonstrate receipt through a standardized electronic process.
Medical record must include the documentation above and a copy of the test results.

Billing Rule

Modifier 90 reimbursement rule

Reference laboratories reporting laboratory services appended with modifier 90 are eligible for reimbursement; non-reference laboratory physicians or other QHPs appending modifier 90 are not eligible for reimbursement.

Reference labs should append modifier 90 to indicate services performed by a reference (outside) laboratory.
Physician office laboratories performing the testing report services without modifier 90 and are eligible for reimbursement when CLIA-certified.

Denial Risk

Panel billing and denial rule

Individual component laboratory codes that together make up a defined laboratory panel will be denied; the provider must submit the comprehensive panel code. For claims with dates of service on or after April 18, 2020, if fewer than all component codes are submitted the components may be considered individually, but claims will be denied when all components comprising a panel are submitted.

Submit the comprehensive panel CPT code (e.g., 80047–80081) rather than individual component codes that constitute that panel.
For DOS on/after April 18, 2020: partial component submissions may be considered individually; full sets of components that match a panel will be denied and must be billed as the panel code.

Documentation Required

Duplicate surgical pathology reporting

When reporting multiple surgical pathology specimens with the same CPT code for the same patient on the same date of service, include modifier 59, XE, XP, XS, XU or 91 to receive separate consideration for each specimen.

If the same surgical pathology CPT code is used for duplicate specimens, append one of: 59, XE, XP, XS, XU, or 91.
Specimens from same anatomic site with same CPT may be reported on one line with multiple units when appropriate.

Billing Rule

Place of Service and Reference Laboratory Billing

When billing laboratory services, report the Place of Service (POS) where the specimen was obtained. Reference laboratories that perform testing outside the ordering site should report services appended with modifier 90 when billing.

Report POS corresponding to specimen collection location (e.g., POS 21/22 for hospitalized specimen, POS 11 for physician office, POS 81 if reference lab drew blood in its own setting).
Reference labs should append modifier 90 to identify services performed by an outside/reference laboratory.

Definitions and Operational Terms

inv-21: Facility POS codes (examples)

Facility POS list (examples)19, 21, 22, 23, 26, 34, 51, 52, 55, 56, 57, 61

UsageUnitedHealthcare uses CMS POS codes to determine facility vs nonfacility status for laboratory reimbursement.

Facility reimbursement implicationManual and automated lab services submitted with these facility POS codes are reimbursable to the facility (not to independent/reference/non-reference labs), except limited exceptions for specialized testing.

inv-22: Date of specimen collection

Primary DOS ruleThe date of service for a laboratory claim is the date the specimen was collected; if collection spans more than one calendar day, use the date collection ended.

Exception for ADLT/molecular pathologyException: for certain ADLT and molecular pathology tests excluded from OPPS packaging, DOS may be the date the test was performed if five specified conditions are met (e.g., performed after outpatient discharge, specimen collected during encounter, results do not guide treatment during encounter, and test is reasonable/medically necessary).

Scope noteApplies to laboratory test claims; see policy for full list of exception conditions.

inv-23: PC/TC indicators

PurposeCMS NPFS Professional/Technical Component (PC/TC) indicators are used to identify purchased diagnostic tests and determine facility reimbursement eligibility.

Indicators referenced (purchased diagnostics)PC/TC indicators 1, 6, and 8 are used to identify Purchased Diagnostic Tests (when purchaser bills, services identified with modifier 90).

Indicators referenced (facility identification)PC/TC indicators 3 and 9 are used to identify services that are not reimbursable to independent/reference/non-reference labs in a facility setting (indicator 3 = technical component only; indicator 9 = not applicable).

inv-24: Organ or Disease-Oriented Panels

DefinitionOrgan or Disease-Oriented Panels are CPT-defined panels (examples include 80047, 80048, 80050, 80051, 80053, 80055, 80061, 80069, 80074, 80076, 80081).

Coding guidancePanels were developed for coding purposes; CPT guidance states do not report two or more panel codes that include the same constituent tests from the same patient collection; select the panel with the greater number of tests.

Example relationshipCPT 80081 has two configurations and a noted precedence relationship with 80055 (see panel definitions for component lists).

inv-25: Duplicate pathology specimens

DefinitionDuplicate pathology specimens are two or more specimens submitted from the same patient that require individual examination and pathological diagnosis; each is assigned an individual code unless modifiers are used to indicate distinct services.

Reporting requirementDuplicate pathology specimens reported with the same surgical pathology CPT code must include modifier 59, XE, XP, XS, XU or 91 to receive separate consideration.

Specimen examplesSeparately identifiable endoscopic biopsies or separate skin lesions are examples of multiple specimens that may be separately coded.

inv-26: Duplicate Laboratory Service

DefinitionDuplicate Laboratory Service: identical or equivalent laboratory component codes submitted for the same patient on the same date of service on separate claim lines or different claims.

Denial and modifiersSuch duplicate services are denied unless an appropriate repeat/distinct procedural modifier is appended (59, XE, XP, XS, XU, or 91).

Relation to MFDDenial applies regardless of the assigned Maximum Frequency per Day (MFD) value for the codes submitted.

inv-27: Independent Laboratory

DefinitionIndependent Laboratory: a laboratory independent of an attending/consulting physician's office and of a qualifying hospital; must meet Federal and State CLIA certification and proficiency testing requirements.

Reimbursement implicationWhen facility obtains tests under arrangements with an Independent Laboratory, only the facility may be reimbursed for manual/automated tests performed in a facility setting (with limited exceptions).

Relation to reference/referring labsReference Laboratories that receive specimens and perform testing are often referred to as Independent Laboratories; services billed by a Reference Laboratory should use modifier 90.

inv-28: Same Individual Physician or Other QHP

DefinitionSame Individual Physician or Other Qualified Health Care Professional: the same individual rendering healthcare services reporting the same Federal Tax Identification number.

Implication for panels/componentsWhen an individual provider reports a component code on the same date of service, that component is considered part of any comprehensive panel reported by that same individual (per panel rules).

Use in duplicate determinationsUsed to determine whether duplicate laboratory services are submitted by the Same Individual versus different providers/groups for reimbursement decisions.