Important Billing Reminders for Lab Orders from Multiple Ordering Sources

Highmark Wholecare recognizes the complexities of laboratory billing, especially when dealing with orders from multiple healthcare professionals.

To ensure accurate and compliant claims processing, we want to clarify the key distinctions between when to bundle and when to separate claims for laboratory services. Adhering to these guidelines will help prevent claim denials and streamline your billing operations.

Key Distinction: When to Bundle vs. When to Separate Claims

The core principle lies in the relationship between the Ordering/Referring Provider (ORP) and the specific lab tests ordered.

• Bundling Required (Single ORP): If a single ORP orders multiple individual components that collectively form a bundled (comprehensive) test, you must report the comprehensive code. Billing individual components in this scenario is considered inappropriate unbundling according to National Correct Coding Initiative (NCCI) guidelines.
• Separate Claims Required (Multiple ORPs): If multiple ORPs order separate individual components, these services must be submitted on separate claims for each ORP. This holds true even if the same laboratory performs the testing on the same date of service. This approach is considered appropriate and compliant.

To further clarify these guidelines, please consider the following examples:

Example 1: Payable Scenario (Multiple ORPs, Separate Claims)

• Scenario: Dr. John orders individual component 80053 for a patient, and Dr. Jane orders individual component 84443 for the same patient on the same date.
• Correct Billing:
  • Claim 1: Submitted under Dr. John's NPI, reporting CPT code 80053.
  • Claim 2: Submitted under Dr. Jane's NPI, reporting CPT code 84443.
• Reasoning: This scenario is appropriate because there are different ORPs, each with their own claim for the service they specifically ordered.

Example 2: Incorrect Scenario & Correction (Single ORP, Bundling Required)

• Scenario: Dr. John orders individual components 80053 and 84443, which are recognized by NCCI as components of a comprehensive bundled code, such as 80050.
• Original (Incorrect) Submission: Claim 1: Submitted under Dr. John's NPI, reporting individual components 80053 and 84443.
• Correction Needed: Rebill Claim 1 with the comprehensive bundled code (80050).
• Reasoning: This correction is necessary because a single ORP ordered multiple components that, when combined, constitute a comprehensive service that should be reported with a single, comprehensive CPT code.

Example 3: Incorrect Scenario & Correction (Multiple ORPs, Billed as Single ORP in Error)

• Scenario: Dr. John orders individual component 80053, and Dr. Jane orders individual component 84443 for the same patient on the same date. However, the lab mistakenly submits both services under Dr. John's NPI.
• Original (Incorrect) Submission: Claim 1: Submitted under Dr. John's NPI, reporting individual components 80053 and 84443, with no mention of Dr. Jane on the claim.
• Correction Needed:
  • Rebill Claim 1 with only the component ordered by Dr. John (80053).
  • Send a new claim (Claim 2) for the component ordered by Dr. Jane (84443), submitted under Dr. Jane's NPI.
• Reasoning: This correction is crucial because there are different ORPs, and each must have a separate claim from the lab for the specific services they ordered.

We appreciate your attention to these important billing details. Following these guidelines will facilitate smoother claims processing and ensure proper reimbursement for the valuable laboratory services you provide.

If you have any questions regarding specific billing scenarios, please contact our provider services department for further assistance at 1-800-392-1147.