OAR 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. [ED. NOTE: Tables referenced are available from the agency.]