Background: Prior to January 2, 2020, laboratories performing molecular pathology and advanced diagnostic lab tests were prevented from billing Medicare directly if those tests were ordered less than 14 days following an outpatient’s discharge from the hospital. Instead, performing labs had to seek their share of the reimbursement from the payment Medicare made to the hospital.
The Date of Service Exception Policy, which went into effect January 2, 2020, eliminated this burdensome issue for performing labs: In short, for the CPT codes included in the Policy, the date of service reported for the test must be the date the test was performed – not the date the specimen was obtained. Performing labs now bill, and receive payment from, Medicare directly as long as the following conditions are met:
• The test was performed following a hospital outpatient’s discharge from the hospital outpatient department;
• The specimen was collected from a hospital outpatient during an encounter;
• It was medically appropriate to have collected the sample from the hospital outpatient during the hospital outpatient encounter;
• The results of the test do not guide treatment provided during the hospital outpatient encounter; and
• The test was reasonable and medically necessary for the treatment of an illness.
The most recent list of designated CPT codes subject to the Laboratory Date of Service Exception can be found in the below PDF.
Additional information and FAQs can be accessed at:
https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/ClinicalLabFeeSched/Clinical-Lab-DOS-Policy.
