Question:

Can a referring lab bill for clinical laboratory diagnostic tests on the CLFS?

Answer:

According to chapter 16, section 40.1.1 of the Medicare Claims Processing Manual, a referring laboratory may bill for clinical laboratory diagnostic tests on the clinical laboratory fee schedule for Medicare beneficiaries it performs if it meets one of the following conditions.

  • It is located in, or is part of, a rural hospital.
  • It is wholly owned by the entity performing such test, the referring laboratory wholly owns the entity performing such test, or both the referring laboratory and the entity performing such test are wholly-owned by a third entity.
  • It does not refer more than 30 percent of the clinical laboratory tests for which it receives requests for testing during the year (not counting referrals made under the wholly-owned condition described above).
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