Date of Service vs APC for PATHOLOGY

 Date of Service rules apply to "all tests" meaning (A) Pathology tests and (B) clinical pathology tests.

However, PACKAGING RULES only apply to clinical laboratory tests (those which are not excepted like human genetics).

Pathology APCs have "S" status which means payable under the APC system and not bundled or discounted in multiples.

Note, however, that due to 419.2(b)(18) add on codes are generally packaged and not payable with their own added APC nor is there any way for the add on code to change the weight of the underlying code's APC assignment.

https://www.law.cornell.edu/cfr/text/42/419.2#b_17

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Friday, September 16, 2022

Where Lab Test OPPS Packaging Comes from (CFR)

 The actual rules stem from the definition of bundled hospital services in one regulation, and the complex 14 day rule in another regulation.

Pretty bizarrely, 42 CFR 419.22(l) [el] excludes clinical diagnostic laboratory tests from payment under the APC system or by APCs.    (*)  

Except as provided by 419.2(b)(17), which does the opposite and bundles most lab tests as packaged costs in the APC system (!!!!!).   That's a cause for whiplash.

And - Further details of the bundling and unbundling occur as a result of the date of service rule aka 14 day rule.  42 CFR 414.510.  For example, this sets a separate date of service for "molecular pathology" tests.

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(*) This means CMS will not take CPT lab codes and crosswalk them to payment by linking them to an APC.   CMS does do exactly this, for some other products.