Special Skilled Nursing Facility (SNF) Billing Exceptions for Laboratory Tests PUB-100 40.4

by  Find-A-Code™
Jan 4th, 2018

When a SNF furnishes laboratory services directly, it must have a Clinical Laboratory Improvement Act (CLIA) number or a CLIA certificate of waiver, and the laboratory itself must be in the portion of the facility so certified. Normally the A/B MAC (A) makes payment under Part B for clinical laboratory tests only to the entity that performed the test. However, the law permits SNFs to submit a Part B claim to the A/B MAC (A) for laboratory tests that it makes arrangements for another entity to perform on the SNF’s behalf. Section 1833(h)(5) of the Act (as enacted by The Deficit Reduction Act of 1984, P.L. 98-369) requires the establishment of a fee schedule for clinical laboratory tests paid under Part B and also requires that, with certain exceptions, only the entity that performed the test may be paid.

The fee schedule applies to all SNF clinical laboratory services.

Where a SNF operates a laboratory that provides laboratory services to patients other then its own patients, it is functioning as a clinical laboratory. The billing for these laboratory services depends upon the HCPCS code as defined in the CMS annual fee schedule releases (laboratory and MPFS), and the arrangements made for payment with the referring entity (e.g., does the SNF or the referring entity bill under the agreement between the two). The SNF is responsible for ascertaining the necessary information for billing the A/B MAC (A). Any questions must be referred to the A/B MAC (A).