Or. Admin. Code § 410-130-0680 - Laboratory and Radiology
(1) The
following tables list the medical and surgical services that:
(a) Require prior authorization (PA) - OAR
410-130-0200 Table 130-0200-1
(PET scans require PA and are included in the table), and;
(b) Are not covered/bundled - OAR
410-130-0220 Table
130-0220-1.
(2) Newborn
screening (NBS) kits and collection and handling for newborn screening (NBS)
tests performed by the Oregon State Public Health Laboratory (OSPHL) are
considered bundled into the delivery fee and, therefore, must not be billed
separately. Replacement of lost NBS kits may be billed with code S3620 with
modifier -TC. The loss must be documented in the client's medical record. NBS
confirmation tests performed by reference laboratories at the request of the
OSPHL will be reimbursed only to the OSPHL.
(3) The Division of Medical Assistance
Programs (Division) covers lab tests performed in relation to a transplant only
if the transplant is covered and if the transplant has been authorized. See the
Division Transplant Services administrative rules (chapter 410, division
124).
(4) All lab tests must be
specifically ordered by, or at the direction of a licensed medical practitioner
within the scope of their license.
(5) If a lab sends a specimen to a reference
lab for additional testing, the reference lab may not bill for the same tests
performed by the referring lab.
(6)
When billing for lab tests, use the date that the specimen was collected as the
date of service (DOS) even if the tests were not performed on that
date.
(7) Reimbursement for
drawing/collecting or handling samples:
(a)
The Division will reimburse providers once per day regardless of the frequency
performed for drawing/collecting the following samples:
(A) Blood - by venipuncture or capillary
puncture, and;
(B) Urine - only by
catheterization.
(b) The
Division will not reimburse for the collection and/or handling of other
specimens, such as PAP or other smears, voided urine samples, or stool
specimens. Reimbursement is bundled in the reimbursement for the exam and/or
lab procedures and is not payable in addition to the laboratory test.
(8) Pass-along charges from the
performing laboratory to another laboratory, medical practitioner, or
specialized clinic are not covered for payment and are not to be billed to the
Division.
(9) Only the provider who
performs the test(s) may bill the Division.
(10) Clinical Laboratory Improvement
Amendments (CLIA) Certification:
(a) The
Division will only reimburse laboratory services to providers who are CLIA
certified by the Centers for Medicare and Medicaid Services (CMS);
(b) CLIA requires all entities that perform
even one test, including waived tests on... "materials derived from the human
body for the purpose of providing information for the diagnosis, prevention or
treatment of any disease or impairment of, or the assessment of the health of,
human beings" to meet certain Federal requirements. If an entity performs tests
for these purposes, it is considered under CLIA to be a laboratory;
(c) Providers must notify the Division of the
assigned ten-digit CLIA number;
(d)
Payment is limited to the level of testing authorized by the CLIA certificate
at the time the test is performed.
(11) Organ Panels:
(a) The Division will only reimburse panels
as defined by the CPT codes for the year the laboratory service was provided.
Tests within a panel may not be billed individually even when ordered
separately. The same panel may be billed only once per day per client;
(b) The Division will pay at the
panel maximum allowable rate if two or more tests within the panel are billed
separately and the total reimbursement rate of the combined codes exceeds the
panel rate, even if all the tests listed in the panel are not ordered or
performed.
(12)
Radiology:
(a) Provision of diagnostic and
therapeutic radionuclide(s), HCPCS A9500-A9699, are payable only when given in
conjunction with radiation oncology and nuclear medicine codes
77401-79999;
(b) HCPCS codes R0070
through R0076 are covered.
(13) Reimbursement of contrast and
diagnostic-imaging agents is bundled in the radiology procedure except for low
osmolar contrast materials (LOCM).
(14) Supply of LOCM may be billed in addition
to the radiology procedure only when the following criteria are met:
(a) Prior adverse reaction to contrast
material, with the exception of a sensation of heat, flushing or a single
episode of nausea or vomiting;
(b)
History of asthma or significant allergies;
(c) Significant cardiac dysfunction including
recent or imminent cardiac decompensation, severe arrhythmia, unstable angina
pectoris, recent myocardial infarction or pulmonary hypertension;
(d) Decrease in renal function;
(e) Diabetes;
(f) Dysproteinemia;
(g) Severe dehydration;
(h) Altered blood brain barrier (i.e., brain
tumor, subarachnoid hemorrhage);
(i) Sickle cell disease, or;
(j) Generalized severe
debilitation.
(15) X-ray
and EKG interpretations in the emergency room:
(a) The Division reimburses only for one
interpretation of an emergency room patient's x-ray or EKG. The interpretation
and report must have directly contributed to the diagnosis and treatment of the
patient;
(b) The Division
considers a second interpretation of an x-ray or EKG to be for quality control
purposes only and will not be reimbursed;
(c) Payment may be made for a second
interpretation only under unusual circumstances, such as a questionable finding
for which the physician performing the initial interpretation believes another
physician's expertise is needed.
Notes
Tables referenced are available from the agency.
Stat. Auth.: ORS 413.042
Stats. Implemented: ORS 414.025 & 414.065
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