General Explanation of Payment (Rev. 2581, 04-01-13) - Laboratory Services

by  Jared Staheli
July 9th, 2015

Outpatient laboratory services can be paid in different ways:

• Physician Fee Schedule;

• 101 percent of reasonable cost (critical access hospitals (CAH) only);

NOTE: When the CAH bills a 14X bill type for a non-patient laboratory specimen, the CAH is paid under the fee schedule.

• Laboratory Fee Schedule;

• Outpatient Prospective Payment System, (OPPS) except for most hospitals in the State of Maryland that are subject to a waiver; or

• Reasonable Charge

Annually, CMS distributes a list of codes and indicates the payment method. Carriers, FIs, and A/B MACs pay as directed by this list. Neither deductible nor coinsurance applies to HCPCS codes paid under the laboratory fee schedule. The majority of outpatient laboratory services are paid under the laboratory fee schedule or the OPPS.

Carriers, FIs and A/B MACs are responsible for applying the correct fee schedule for payment of clinical laboratory tests. FIs/AB MACs must determine which hospitals meet the criteria for payment at the 62 percent fee schedule. Only sole community hospitals with qualified hospital laboratories are eligible for payment under the 62 percent fee schedule. Generally, payment for diagnostic laboratory tests that are not subject to the clinical laboratory fee schedule is made in accordance with the reasonable charge or physician fee schedule methodologies (or at 101 percent of reasonable cost for CAHs).

For Clinical Diagnostic Laboratory services denied due to frequency edits contractors must use standard health care adjustment reason code 151 - “Payment adjusted because the payer deems the information submitted does not support this many services.”


General Explanation of Payment (Rev. 2581, 04-01-13) - Laboratory Services. (2015, July 9). Find-A-Code Articles. Retrieved from

© InnoviHealth Systems Inc

Article Tags  (click on a tag to see related articles)

Publish this Article on your Website, Blog or Newsletter

This article is available for publishing on websites, blogs, and newsletters. The article must be published in its entirety - all links must be active. If you would like to publish this article, please contact us and let us know where you will be publishing it. The easiest way to get the text of the article is to highlight and copy. Or use your browser's "View Source" option to capture the HTML formatted code.

If you would like a specific article written on a medical coding and billing topic, please Contact Us.


innoviHealth Systems, Inc.
62 East 300 North
Spanish Fork, UT 84660
Phone: 801-770-4203 (9-5 Mountain)
free demo
request yours today
for any budget
sign IN
welcome back!

Thank you for choosing Find-A-Code, please Sign In to remove ads.