CAH Outpatient Criteria Changes for Specimen Collections

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  • June 1, 2009
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A provision in the Medicare Improvements for Patients and Providers Act (MIPPA) of 2008 will soon change the policy of who is considered a critical access hospital (CAH) outpatient when outpatient clinical diagnostic laboratory services are provided.

Effective July 1, a CAH outpatient is no longer required to be physically present in the CAH at the time a specimen is collected for the CAH to be paid at 101 percent of reasonable cost.
To qualify, the patient must receive outpatient services in the CAH the same day the specimen is collected or the specimen must be collected by an employee of the CAH. Neither condition need be met if the patient is in the CAH or a facility that is provider-based to the CAH when the specimen is collected.
Submit a Type of Bill (TOB) 85X when any of these requirements are met. Continue to bill tests for non-patients on the TOB 14X to receive payment based on the clinical laboratory fee schedule.
Different rules apply for rural health clinics (RHC) and federally qualified health clinics (FQHC).
For complete details, please refer to the Centers for Medicare & Medicaid Services (CMS) transmittal 1729, CR6395, issued May 8 or MLN Matters MM6395.

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