Changes in Type of Bill Codes for OPPS Hospitals Billing Some Outpatient Laboratory Tests

Summary by:  Barbara Rudolph, NAHDO Consultant

Background: The NUBC was concerned about the CMS intention, based on the 2014 OPPS Rule, to instruct hospitals to utilize the Type of Bill code 014x for reporting any unrelated outpatient laboratory tests performed the same day as other outpatient services, irrespective of whether the hospital lab services are for a patient or a non-patient.  That however, was not in accordance with the NUBC definition for the 014x TOB. The NUBC definition indicates that TOB 014x can only be used to present billing for laboratory services when these services are provided only to non-patients (hospital laboratory receives a specimen and does not see the patient or draw the sample).  Should a patient present  themselves at the laboratory of the hospital for a lab test, that patient will be registered as an outpatient and billed using TOB 013x Hospital Outpatient.  NUBC sent a letter to CMS clarifying how the TOB could be used under NUBC definitions. (see link to letter and CMS response below).

CMS Actions: In response to concerns relayed by NUBC, CMS published a MLN Matters (SE 1412) updated requirements for Change Request (CR 8572) which describes the Update to the 2014 Hospital Outpatient Clinical and Diagnostic Laboratory Test Payment and Billing.  This guidance affects outpatient clinical diagnostic lab tests furnished in CY 2014 by OPPS hospitals that are eligible for separate payment under Clinical Laboratory Fee Schedule (CLFS).  To address the NUBC concerns for CY 2014, a new modifier will be used on the 013x TOB when non-referred lab tests are eligible for separate payment under the CLFS (see details in MLN).  The new modifier will be in effect July 1, 2014.  In the interim, hospitals can continue to use the TOB 014x in accordance with the exceptions listed in the CY 2014 OPPS. What does this mean for hospital outpatient discharge data?  Possibly, the bills resulting when OPPS hospitals  (viewed by CMS as a laboratory) bill an unrelated service (to other services provided in the outpatient setting), there may be duplicated discharges, one with aTOB 014x, and the other using the 013x TOB for packaged lab tests.   For more details go to: