Skip to Content

Provider Manual

Reference (Outside) Laboratory Billing Protocol

Last Updated on January 24, 2019

Reference (Outside) Laboratory Billing Protocol (does not apply to BadgerCare Plus)

If the physician is billing for the lab service:

  1. The provider should bill the appropriate lab CPT code (8XXXX).
  2. Append modifier 90 to the lab CPT code to indicate it was sent out.
  3. Enter the name of the outside lab in box 19 on the CMS 1500 claim form.
  4. Bill the specimen handling (CPT 99000 or 99001) and venipuncture (CPT 36415) when appropriate.
  5. Only one handling fee (CPT 99000 or 99001) will be reimbursed per member, per provider sending out, per lab, per date of service, regardless of the number of specimens sent to a specific lab. 

a. Exception: If different handling or shipping types are needed to send more than one specimen to the same lab, more than one handling fee may be considered if supporting documentation is provided for review.
b. Bill each handling fee as a separate line item on the claim; do not quantity bill.

If the Reference Lab is billing for the lab service:

  1. The Lab should bill the appropriate lab CPT code (8XXXX). 
  2. In box 24b on the CMS 1500 claim form, enter place of service 81. 
  3. The physician may bill for specimen handling (CPT 99000 or CPT 99001) or venipuncture (CPT 36415) when appropriate. 
  4. Only one handling fee (CPT 99000 or CPT 99001) will be reimbursed per member, per provider sending out, per lab, per date of service, regardless of the number of specimens sent to a specific lab. 

a. Exception: If different handling or shipping types are needed to send more than one specimen to the same lab, more than one handling fee may be considered if supporting documentation is provided for review.
b. Bill each handling fee as a separate line item on the claim; do not quantity bill.