Ga. Medicaid Part II Policies & Procedures for Hospital Services, Appendix I

As described in Section 1001.3, effective on and after October 1, 1984, clinical diagnostic

laboratory services performed in hospital-based outpatient facilities will be reimbursed at the

littlest of 60% of the prevailing charge or the submitted charges. As stated in Section 902, the

coding system required for reimbursement of these charges is the Current Procedural

Terminology (CPT). These codes must be used in conjunction with the appropriate laboratory

revenue code. Additionally, the Principal Diagnosis Description and Principle Diagnosis Codes

(ICD-10 CM) must be identified on the submitted claim.

A. The following laboratory services are non-covered by the Division.

i. CPT procedures deleted from previous and current editions of the Current Procedural

ii. Terminology book and those shown as “Unlisted Procedures” which end in “99.”

iii. Collection fees except for the services identified in Appendix E.

iv. Services provided free of charge to Medicaid members by State or public laboratories.

(Refer to Appendix E).

B. Exclusions:

i. The following laboratory test codes are excluded from the schedule of maximum

allowable payments and will be reimbursed in accordance with the policy outlined in

Section 1001.3.

1. 85060-85175, Codes dealing with bone marrow smears and biopsies

2. 88104-88140-Certain cytopathology services

3. 86920-Transfusion Medicine

ii. Reimbursement of the clinical laboratory CPT codes is based on the Medicaid’s

pricing methodology for outpatient lab services which pays the lesser of the following:

1. The Medicaid Allow Amount {Medicaid Rate + Hospital Add-On Rate

(Medicaid Rate x .1188) x Number of Units} OR The Medicare Allowed Amount

(Medicare Rate x Number of Units).