Lab and Radiology Billing
When submitting claims for laboratory or radiology services rendered in a
hospital setting, inpatient or outpatient, and you are a professional provider, use modifier 26 to
indicate that you are billing for the professional component only. The hospital will submit claims for
the technical component.
When submitting claims for laboratory or radiology services rendered in an
office setting and you are a professional provider, indicate whether or not you are billing for the
global fee or only the professional component. Use modifier 26 to indicate you are billing for the
professional component only if sending the sample to a laboratory. You should also check “yes” in Box 20
of the CMS-1500 or 837 transaction. This allows payment to the laboratory for the
technical component. If you don’t use a modifier and don’t indicate “yes” in Box 20 of the CMS-1500,
you will be paid the
global fee. Should the laboratory subsequently bill for the technical
component, that claim
will be denied.
Note: Clinical labs
billing for services for inpatient hospital patients must bill the
facility, not TRICARE, for the lab tests. Repeated failure to follow
this rule will cause the clinical lab to have all claims returned to
them without processing.
Venipuncture
Venipuncture is denied
or paid based on the setting in which it is provided. Denial or payment is
also determined by whether
or not the lab results are read by the provider of care. When submitting venipuncture claims,
specify “yes” or “no” in Box 20 of the CMS-1500 or 837 transaction to indicate if an outside
laboratory was utilized. If the labs are drawn in a provider’s office but
read in an outside laboratory,
TRICARE pays for the venipuncture.
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