Effective Date: October 14, 2019

Purpose:
Provide guidelines for technical/professional component part of laboratory services when appropriately billed by professional providers.

Scope:
Products included:

• NJ FamilyCare/Medicaid Plan
• Fully Integrated Dual Eligible Special Needs Plan (FIDE-SNP)

Definitions:

• CPT Code 85060: Blood smear, peripheral, interpretation by physician with written report

Policy:
Technical/Professional Component of Laboratory Services (CPT codes 80000-89999) billed in a Facility Setting:

Horizon NJ Health shall not consider for separate reimbursement the technical and/or professional component of laboratory services when billed by a professional provider and performed in the following facility settings:

• 19 (Outpatient hospital-off campus)
• 21 (Inpatient hospital)
• 22 (Outpatient hospital-on campus)
• 23 (Emergency room)
• 51 (Inpatient psychiatric facility)
• 52 (Psychiatric facility-partial hospitalization)
• 61 (Comprehensive inpatient rehabilitation facility) or
• 81 (Independent laboratory)

Reimbursement of the professional component only of laboratory services shall be considered for reimbursement for the following specialties when performed in a facility setting:

• Dermatology
• Genetics
• Hematology
• Laboratory
• Pathology

Procedure Code 85060 (Interpretation of Blood Smears):
Horizon NJ Health shall consider for reimbursement procedure code 85060 when performed by a professional provider and when services are rendered in the following facility settings:

• 19 (Outpatient hospital-off campus)
• 21 (Inpatient hospital)
• 22 (Outpatient hospital-on campus)
• 23 (Emergency department), or
• 24 (ASC)

Horizon NJ Health shall consider for reimbursement procedure code 85060 when services are performed by a Hematology-Oncology specialists and rendered in an office or facility setting.

Procedure:
Horizon NJ Health shall deny the technical component of laboratory services (CPT Codes 80000-89999) when performed by a professional provider when services are rendered in the facility settings previously identified above.

Horizon NJ Health shall deny the professional component of laboratory services (CPT Codes 80000-89999) when performed by a professional provider with a specialty other than Dermatology, Genetics, Hematology, Laboratory, or Pathology when rendered in the facility settings previously identified above.

Horizon NJ Health shall deny procedure code 85060 when performed by a professional provider when the service is not performed in the facility settings previously identified above.

Limitations and Exclusions:
While reimbursement is considered, payment determination is subject to, but not limited to:

• Benefit Limitations
• The terms of any applicable provider participation agreement;
• Routine claim editing logic, including but not limited to incidental or mutually exclusive logic;
• Medical necessity; and
• Applicable law, regulatory guidance, government mandates, and the terms of the Managed Care Contract between Horizon NJ Health and the New Jersey Department of Human Services, Division of Medical Assistance and Health Services.

References:

Medicare Claims Processing Manual, Chapter 12, Physicians/Nonphysician Practitioners cms.gov/Regulations-and-Guidance/Guidance/Manuals/downloads/clm104c12.pdf

Medicare Claims Processing Manual, Chapter 16, Laboratory Services cms.gov/Regulations-and-Guidance/Guidance/Manuals/downloads/clm104c16.pdf