Covered and Excluded Billing Situations

(1) Covered Billing Situations. Except as provided in 101 CMR 320.03(2), the method of determining rates of payment contained in 101 CMR 320.00 apply to clinical laboratory services provided to publicly aided individuals, with the following conditions. (a) If clinical laboratory services are performed by an independent clinical laboratory, then the independent clinical laboratory must bill the governmental unit directly. The independent clinical laboratory may not bill indirectly by having a physician or dentist bill either the payer or the patient for services performed by the independent clinical laboratory. (b) If clinical laboratory services are performed by a registered physician or dentist, or by an agent under his or her direct supervision, in his or her private medical office or clinic, then the registered physician or dentist must bill the governmental unit directly. (2) Excluded Billing Situations. 101 CMR 320.00 and the rates of payment contained in 101 CMR 320.00 do not govern the rates of payment for clinical laboratory services if (a) the service is provided in state institutions by a state-employed physician, dentist, or dentist consultant; (b) the service is provided by a physician or dentist whose salary from a hospital or affiliated medical school includes compensation for professional services rendered to patients; or (c) the physician, dentist, or independent laboratory does not customarily bill private patients without health insurance under comparable circumstances. (3) Professional and Technical Component Services. Some laboratory services have both professional and technical components. The professional component is set forth in 101 CMR 316.00: Rates for Surgery and Anesthesia Services, while the technical component is set forth in 101 CMR 320.00. (a) The relevant codes for laboratory services containing both professional and technical components are 83020, 84165, 84166, 84181, 84182, 85390, 85576, 86255, 86256, 86320, 86325, 86327, 86334, 86335, 87164, 87207, and 89060. (b) Surgical pathology services are excluded from 101 CMR 320.00 and instead included in 101 CMR 316.00: Rates for Surgery and Anesthesia Services. Surgical pathology services include codes 80503, 80504, 80505, 80506, 85060, 85097, 85396, 86077, 86078, 86079, 86153, 86486, 86490, 86510, 86580, 88104, 88106, 88108, 88112, 88120, 88121, 88125, 88141, 88160, 88161, 88162, 88172, 88173, 88177, 88182, 88184, 88185, 88187, 88188, 88189, 88199, 88291, 88299, 88300, 88302, 88304, 88305, 88307, 88309, 88311, 88312, 88313, 88314, 88319, 88321, 88323, 88325, 88329, 88331, 88332, 88333, 88334, 88341, 88344, 88346, 88348, 88350, 88355, 88356, 88358, 88360, 88361, 88362, 88363, 88365, 88366, 88367, 88368, 88369, 88374, 88375, 88377, 88380, 88381, 88387, 88388, 88399, 89049, 89060, 89220, 89230, and 89240.