Last week you gave a list of options that a referring lab must meet to be able to bill for clinical lab tests on the CLFS. We are interested in the one about the lab not referring more than 30 percent of the tests for which it receives testing requests, etc. How does CMS determine the 30 percent exception option?


The Centers for Medicare & Medicaid Services provides the following examples.

Example 1: A laboratory receives requests for 200 tests, performs 139 tests, and refers 61 tests to a non-related laboratory. All tests referred to a non-related laboratory are counted. Thus, 30.5 percent (61/200) of the tests are considered tests referred to a non-related laboratory and, since this exceeds the 30 percent standard, the referring laboratory may not bill for any Medicare beneficiary laboratory tests referred to a non-related laboratory.

Example 2: A laboratory receives requests for 200 tests, performs 139 tests and refers 15 to a related laboratory and 46 to a non-related laboratory. Only 23 percent of the tests were referred to non-related laboratories. Since this is less than 30 percent, the referring laboratory may bill for all tests.


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