CMS Pub. 100-04, ch. 7, § 90

Section 1833(h)(5) of the Act (as enacted by The Deficit Reduction Act of 1984, Public

Law 98-369) requires the establishment of a fee schedule for clinical diagnostic

laboratory tests paid under Part B.

Section 1833g(5)(A)iii of Title XVIII provides that "in the case of a clinical diagnostic

laboratory test provided under an arrangement (as defined in §1861(w)(1)) made by a

hospital, critical access hospital or skilled nursing facility, payment shall be made to the

hospital or skilled nursing facility."

SNFs must make arrangements under Part A and may make arrangements under Part B

under which the SNF bills the intermediary and receives payment. Under this process,

the SNF pays the lab for services whatever amount the SNF and the lab agree on, and the

beneficiary may not be charged by the lab.

Where the SNF and a lab have entered into such an arrangement, the arrangement may

include Part A only or may include Part A and Part B. Such an arrangement is voluntary

on the part of both the lab and the SNF for Part B services.

In the absence of such an arrangement under Part B, the lab may bill the program for lab

services furnished to residents for whom Part A cannot be paid, and for SNF outpatients,

and the SNF may not bill the program for these services. Hospital labs and labs in other

SNFs would bill the intermediary. Independent labs would bill the carrier.

Laboratory tests performed for the SNF's Medicare inpatients covered under Part A are

included in the PPS SNF payment.

If the FI receives fee amounts for HCPCS included on both the clinical diagnostic

laboratory fee schedule and the SNF extract of the MPFS, the SNF receives the amount

on the laboratory fee schedule.

Payment is made for specimen collection fees and travel allowance as discussed in

Medicare Claims Processing Manual, Chapter 16, "Laboratory Services from

Independent Labs, Physicians, and Providers."

Bill type 22X for lab services to Part B residents and 23X for nonresidents should be

used.

Neither deductible nor coinsurance applies to lab fee schedule payments.

See the Medicare Claims Processing Manual, Chapter 16, "Laboratory Services from

Independent Labs, Physicians, and Providers," for additional coverage, billing, and

payment requirements.