Jan, when the physician office bills for labs that are sent to an outside lab, they should first of all have a billing agreement with that lab; it will state that the lab will bill the physician's office for the tests, not the insurance company (except for Medicare/Medicaid - those need to be billed by the CLIA certified lab). Then, the physician's office should file the lab CPT codes to you (the ASO/TPA) with a 90 modifier, indicating that it went to an outside lab but they are billing for it. Those codes should be on a different CMS 1500 with the lab location in Box 32. For Medicare, there are only some labs that are CLIA-waived and can be filed by a physician's office with the QW modifier. When I worked for insurance, if we got claims for lab from both the physician (with the 90 modifier) and the lab, the second one received would deny as a duplicate, even with the modifier, so that we didn't pay for the lab twice. I remember telling Dr's offices that the lab had already billed - they usually weren't very happy!!
Originally Posted by Jan S Plummer
Lucinda (Cindy) McGarry, CPC-P
Avera Health Plans
Education Office Sioux Falls SD Local Chapter
Past President Sioux Falls SD Local Chapter