by Jared Staheli
July 10th, 2015
See the Medicare Benefit Policy Manual, Chapter 11, for a description of laboratory services included in the composite rate. With the implementation of the ESRD PPS, effective for claims with dates of service on or after January 1, 2011, all ESRD-related laboratory services are included in the ESRD PPS base rate.
Clinical laboratory tests can be performed individually or in predetermined groups on automated profile equipment. A specimen collection fee determined by CMS will be allowed only in the following circumstances:
• Drawing a blood sample through venipuncture (i.e., inserting into a vein a needle with a syringe or vacutainer to draw the specimen).
• Collecting a urine sample by catheterization.
Special rules apply when such services are furnished to dialysis patients. The specimen collection fee is not separately payable for patients dialyzed in the facility or for patients dialyzed at home under reimbursement Method I. A specimen collection fee is also not separately payable when an ESRD facility is collecting a specimen for transplant eligibility or other transplant requirements. Payment for specimen collection is included under the ESRD PPS, regardless of whether the laboratory test itself is included in the ESRD PPS or is separately billable with the AY modifier (see §40.6 of this chapter).
Fees for taking specimens in the hospital setting, but outside of the dialysis unit, for use in performing laboratory tests not included in the ESRD composite rate may be paid separately.