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CLIA Waived Billing

SuperCoder Posted Wed 18th of December, 2013 12:08:51 PM

What if anything can be billed when a physician is out of the office? Things like venipunctures, urinalysis or FOBT. Documentation from a website/article would be really helpful.

SuperCoder Answered Wed 18th of December, 2013 14:33:11 PM

Please see this Q/A from

Our clinic does protimes in the office and has a CLIA (Clinical Laboratory Improvement Amendments) license in place to do these. I do understand that this is a lab, but since it is a CLIA waived test can we bill this service to Medicare with the QW modifier (CPT 85610)?
Whether you have a CLIA license or not, Independent RHCs bill all laboratory services to the carrier or A/B MAC on a 1500 form, and provider-based RHCs bill all lab tests to the FI or A/B MAC on a 1450 or UB-04 form under the host provider's bill type. In either case payment is made under the fee schedule; therefore, HCPCS codes are required for lab services. CLIA waived services will also need to be billed with a QW modifier.

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We are a provider-based RHC where we perform lab draws/specimen collections. The draws/venipuncture's are not performed by a hospital employee and there may or may not be a face-to-face encounter. We then send the specimen over to our Method II Critical Access Hospital (CAH) where the test is performed. How should the RHC and CAH bill for this service?
A blood draw by itself does not constitute a RHC encounter. Keep in mind that in order for a RHC to bill a physician visit, a face-to-face encounter has to be medically reasonable and necessary. If the patient only came in for a blood draw, you cannot bill for a visit. If a physician sees a patient and determines that blood work is needed, then the lab portion will be billed by the CAH. The RHC encounter can be billed on the RHC claim. If there is no physician visit, then the RHC would not be able to bill anything.

Venipunctures are not a RHC service; therefore, they may not be billed by the RHC. These would be billed by the CAH.

A CAH will be paid 101 percent of reasonable cost for outpatient clinical diagnostic laboratory tests. Effective for services furnished on or after July 1, 2009, the individual is no longer required to be physically present in a CAH at the time the specimen is collected. However, the individual must be an outpatient of the CAH, as defined at 42 CFR §410.2 and be receiving services directly from the CAH. In order for the individual to be receiving services directly from the CAH, the individual must either be receiving outpatient services in the CAH on the same day the specimen is collected, or the specimen must be collected by an employee of the CAH or of a facility provider-based to the CAH.

So in this particular case, because the RHC is a CAH-based provider, the CAH would bill the lab services using an 85x TOB.

SuperCoder Posted Thu 19th of December, 2013 16:00:47 PM

We are not an RHC site, so the above reply does not answer our question. Sorry!

SuperCoder Answered Fri 20th of December, 2013 11:03:27 AM

This question has to do with rules for lab management – a physician must have oversight of a lab. Let me research on this and we will post the answer soon.


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