Outside (Reference) Labs Billing Protocol
The outside lab has to bill the BadgerCare Plus carrier for the test(s). The clinic can bill a lab handling fee when sent to an outside lab. However, Security Health Plan BadgerCare Plus will not cover the phlebotomy fee (venipuncture) since it is bundled with the lab test. The BadgerCare Plus member cannot be billed for routine venipuncture.
When a specimen is sent to an outside lab:
- Check “Yes” in Box 20-Outside Lab on the CMS 1500 form.
- Do not bill the CPT lab code (the outside lab bills insurance carrier for it).
- Bill the handling fee (CPT 99000).
- Put the name of the outside lab in Box 19.
Additional Rules for All Outside Labs
- One lab handling fee is paid to a provider per recipient, per outside lab, per date of service, regardless of the number of specimens sent to the lab.
- More than one handling fee is paid only when specimens are sent to two or more labs for one recipient on the same date of service. Each handling fee must be billed by line item; CPT 99000 does not allow a quantity. When more than one outside lab is used, list all lab names used in Box 19.