Laboratory services

Members are required to obtain a Physician order for laboratory services. Reimbursement for laboratory services is a global (i.e., technical and professional component) payment for services rendered. Payment is made directly to the facility according to the hospital’s contracted rates (if there is no separate designated laboratory agreement).

Capitated laboratory services 

Laboratory services for HMO/POS Members are generally provided by the designated Provider under the Capitated Laboratory Program. A complete listing of the services included in this program can be found at www.ibx.com/medpolicy. Laboratory services that are excluded from capitation are paid at the hospital’s contracted rate.

STAT laboratory services for HMO/POS Members 

If an HMO/POS Member receives STAT laboratory services from their capitated laboratory Provider, these services are included in the capitated laboratory payment and are not separately reimbursed. However, if the HMO/POS Member is not at their capitated site for STAT laboratory services, payment for the STAT testing will be reimbursed according to the hospital contracted rates. A Referral is not required for any STAT laboratory services

Observation services 

Observation services are considered an outpatient service, and involve the use of a bed and periodic monitoring by the facility’s nursing or other ancillary staff in order to evaluate and treat an individual’s condition or determine the need for a possible inpatient admission. 

Outpatient surgery 

Outpatient surgery reimbursement represents an all-inclusive payment for all facility Covered Services provided during and related to the surgical procedure. The all-inclusive payment includes services/items provided in conjunction with surgical procedures but excludes certain implantable devices. Please refer to the Outpatient Implantable Devices section on page 7.11 for more information. 

All services related to the outpatient surgery should be billed on the same claim. Surgeries performed on multiple dates should be billed on separate claims for each surgical date of service and include all of the services related to each surgery. Do not bill multiple surgical dates of service on the same claim. 

Outpatient surgical procedures are assigned a surgical category, which determines the level of reimbursement. Surgical procedures not listed on the Outpatient Fee Schedule are individually reviewed for payment consideration when performed in a hospital outpatient setting.

Services included in reimbursement for outpatient surgery 

Outpatient services rendered prior to an outpatient surgical procedure. Outpatient procedures, such as preadmission diagnostic services and other services related to the surgical procedure, can occur before the date of the surgical procedure but are not separately reimbursable.

Preoperative examinations. Services billed with a diagnosis code for preoperative examinations are not separately reimbursable. 

Preadmission diagnostic services. Reimbursement for outpatient surgical procedures includes payment for preadmission diagnostic services. Charges for preadmission diagnostic services must be included on the surgical claim. Diagnostic services provided to a Member within 30 days prior to and including the date of the Member’s surgery are included in the surgical procedure payment. Diagnostic services include the following revenue/procedure codes*: 

– 0254: Drugs incident to other diagnostic services 

– 0255: Drugs incident to radiology 

– 030X: Laboratory

– 031X: Laboratory pathological

– 032X: Radiology diagnostic

– 0341, 0343: Nuclear medicine, diagnostic/diagnostic radiopharmaceutical

– 035X: Computed topography (CT) scan 

– 0371: Anesthesia incident to radiology 

– 0372: Anesthesia incident to other diagnostic services 

– 040X: Other imaging services 

– 046X: Pulmonary function 

– 0471: Audiology diagnostic 

– 0482: Cardiology, stress test 

– 0483: Cardiology, echocardiology

– 053X: Osteopathic services 

– 061X: Magnetic resonance technology (MRT) 

– 062X: Medical/surgical supplies, incident to radiology or other diagnostic services 

– 073X: Electrocardiogram (EKG/ECG) 

– 074X: Electroencephalogram (EEG) 

– 0918: Testing, behavioral health 

– 092X: Other diagnostic services

 Observation services. When Outpatient surgical claims are paid according to the fee schedule, there is no additional reimbursement for observation room services

Multiple surgical procedures 

When multiple outpatient surgical procedures are performed during the same date of service, Providers may bill multiple outpatient surgical procedures with multiple surgical revenue codes. IBC will reimburse the primary procedure at 100 percent of the contracted rate and each eligible secondary procedure at 50 percent of the contracted rate. The primary service on each claim will be determined based on the highestallowable contracted rate. When a claim has multiple procedures with the same highest-allowable contracted rate, the first listed procedure with the highest allowable will be reimbursed as primary, all other eligible procedures will be reimbursed as secondary.

Incidental procedures 

Services identified as incidental procedures (IP) on the Outpatient Fee Schedule may or may not be eligible for reimbursement. When multiple surgical procedures are performed on the same date of service, procedures identified as IP are considered incidental to the primary procedure and are not eligible for additional reimbursement. However, payment for an IP is made when that procedure is the only surgical procedure performed or when it is the primary procedure for the episode of care.