RE: samurai pathologist/ Dr Margaf

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From:"Weems, Joyce" <> (by way of histonet)
To:histonet <>
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I may be able to shed some light on this subject, according to
information that I received by the billing department at Emory
University last spring. The billing manager for Emory Labs attended a
meeting with HCFA attorneys. He was told that "Medicare now requires
that when a hospital obtains laboratory services for its own patients,
whether outpatients or inpatients, under arrangements with clinical
laboratories or other hospital laboratories, only the originating
hospital may bill Medicare for the arranged services." He faxed a copy
of the "January Question of the Month from National Intelligence Report
to me.

To quote:
Question:   When a hospital refers tests for a Medicare beneficiary who
is not an inpatient to an outside laboratory, who should bill Medicare
for the tests: the referring hospital or the laboratory performing the

Answer:    The answer depends in part on whether the beneficiary is an
outpatient of the hospital or a "nonpatient" receiving services as part
of the hospital's lab outreach services, and in part on wheter the
reference lab is another hospital lab or an independent clinical
 	When a hospital lab refers tests for an outpatient (that is, a patient
who actually comes to the hsopital for the services) to an outside lab
(whether another hospital lab or an independent lab) "under
arrangements" with the reference lab, the reference lab bills the
hospital arranging for the service and the hospital bills Medicare.
	When a hospital lab with an outreach program refers test for a
nonpatient to another hospital lab, the referring hospital bills
Medicare, but if the specimens are referred to an independent lab,
Medicare's 70/30 rule kicks in. Under this rule , the referring lab may
bill Medicare if it refers no more that 30% of the tests for which it
receives orders to an outside lab; otherwise the independent lab should
bill Medicare.
	For 1998, payment is made at the lowest of three possible rates: the
carrier's lab fee schedule, the national limitation amount (the national
cap, now set at 74% of the median), or the provider's charge.
	Caution: If a hospital lab or an entity wholly owned or operated by the
hospital performs tests on a patient within three days of the of the
patient's admission to the hoispital (the "DRG Window"), payment for the
test is bundled into the inpatient payment under Part A, and the tests
may not be separately billed.

What brought this all about was my investigation into billing consults
on pathology cases. What we take this to mean is that we bill the
patient for the muscle biopsy we send to Emory to be processed and Emory
bills us. When we send a case for consult, we ask Emory to bill the
patient. However, if their pathologist requests immunos that have not
been done here, we would have to bill the patient for those.

I know this is long and confusing, but hopefully it will help answer
your question!

Cheers to you and the US Government!!! Joyce :>)
>From: 	SEARNJ[]
>Sent: 	Thursday, November 19, 1998 11:48 AM
>Subject: 	samurai pathologist/ Dr Margaf
>In March of this year you commented on billing/cpt coding of consults. I have
>"billing expert" saying that if patient is in hospital, hospital has to
>patient, consultant (flow, em, etc.) MUST bill hospital. Does this change if
>you have a private lab? Flow would have to originate from hospital but how
>about slide consults at private-on work that originated at a hospital that
>no processing dept. Even after 30 yearw, I can say I can get mighty confused-
>We (the pathology staff ) will soon become private and my "hat" will have to
>change. I know that the discussion has been held in the past-especially with
>archival HER2nu. Can we have a final decision and can a written reference be
>sited so I can have a reference? Thanks for the reliving the past!

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