Laboratory Services Performed in a Facility Setting
The established policy for reimbursement of laboratory services performed in a facility setting is consistent with the policy not to pay for duplicative laboratory services. Manual and automated laboratory services submitted by a reference or non-reference laboratory provider with a CMS facility POS 21, 22, 23, 26, 34, 51, 52, 56 or 61 will not be reimbursable. These services are reimbursable to the facility. When hospitals obtain manual or automated laboratory tests for patients under arrangements with a reference laboratory or pathology group, only the hospital can bill for the services. Note: AmeriChoice will make an exception to this policy for reproductive laboratory medicine procedures 89250-89398 when the hospital laboratory is not equipped to perform these specialized services and refers them to a reproductive laboratory. In the event that both a hospital and a reference laboratory report the same service on the same day for the same member, only the hospital reproductive laboratory services will be allowed. AmeriChoice uses the CMS National Physician Fee Schedule (NPFS) Professional Component/Technical Component (PC/TC) indicators 3 and 9 to identify laboratory services without a professional or technical component that are not reimbursable to a reference or non-reference provider in a facility setting.
• PC/TC indicator 3: Technical Component Only Codes
• PC/TC indicator 9: PC/TC Concept Not Applicable
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