Electronic Claim Submission to A/B MACs (B) (Rev. 3089, 01-01-15) - Billing for Clinical Laboratory Tests

by  Jared Staheli
July 9th, 2015

Electronic Claim Submission

SC X12 837 professional claim format (HIPAA compliant version):

CLIA number:

An electronic claim for laboratory testing will require the presence of the performing (and billing) laboratory’s CLIA number; if tests are referred to another laboratory, the CLIA number of the laboratory where the testing is rendered must also be on the claim. An electronic claim for laboratory testing must be submitted using the following rules:

ANSI Electronic claim: the billing laboratory performs all laboratory testing.

The independent laboratory submits a single claim for CLIA-covered laboratory tests and reports the billing laboratory’s number in:

X12N 837 (HIPAA version) loop 2300, REF02. REF01 = X4

ANSI Electronic claim: billing laboratory performs some laboratory testing; some testing is referred to another laboratory.

The ANSI electronic claim will not be split; CLIA numbers from both the billing and reference laboratories must be submitted on the same claim. The presence of the ‘90’ modifier at the line item service identifies the referral tests. Referral laboratory claims are only permitted for independently billing clinical laboratories, specialty code 69.

The billing laboratory submits, on the same claim, tests referred to another (referral/rendered) laboratory, with modifier 90 reported on the line item and reports the referral laboratory’s CLIA number in:

X12N 837 (HIPAA version) loop 2400, REF02. REF01 = F4

EXAMPLE: A physician has ordered the DEF independent laboratory to perform glucose testing and tissue typing for a patient. Since the DEF Laboratory is approved to perform only at the routine chemistry LC level (which includes glucose testing), it refers the tissue-typing test to the GHI laboratory.

The DEF laboratory submits a single claim for the glucose and tissue typing tests; the line item service for the glucose test is submitted without a ‘90’ modifier since the DEF laboratory performed this test. The CLIA number for the DEF laboratory is entered in the electronic claim in:

X12N 837 (HIPAA version) loop 2300, REF02. REF01 = X4

On the same claim, the line item service for the tissue typing test is submitted with a ‘90’ modifier and the referral/rendering GHI laboratory’s CLIA number is entered on the electronic claim in:

X12N 837 (HIPAA version) loop 2400, REF02. REF01 = F4

Reference Laboratory’s Address:

An electronic claim for laboratory testing requires the presence of the performing and billing laboratory’s, name and address. The performing laboratory for a service with a line item CPT 90 modifier requires provider information for the appropriate 837 loop.

NOTE: Effective for claims submitted with a receipt date on and after April 1, 2015, the billing physician or supplier must report the name, address, and NPI of the performing physician or supplier on the claim on reference laboratory claims, even if the performing physician or supplier is enrolled in a different B/MAC jurisdiction. See Pub. 100-04, Chapter 1, § 10.1.1 for more information regarding claims filing jurisdiction.

References:

• Pub 100-04 Medicare Claims Processing Manual - Chapter 16