Bill Type 14X Redefined

Medicare Expands Use of Bill Type 14X

Medicare expanded the use of the hospital bill type 14X at the beginning of 2014. Prior to the change, bill type 14X was used for hospital outpatient laboratory non-patient specimen. That meant only the specimen went to the lab, the patient didn't go to the hospital in person. Following the change, the patient may or may not be seen at the hospital.

When to Use Hospital Bill Type 14X

Health Insurance Claims
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  1.  If the patient presents to the hospital and receives only laboratory services, the services can be billed on a bill type 14X.
  2. If the patient presents to the hospital and receives both laboratory and outpatient services with a different physician on each order, the laboratory services can be billed on a bill type 14X and the outpatient services can be billed on a bill type 13X.

Why the Change?

According to CMS.gov, traditionally Outpatient Prospective Payment System (OPPS) hospitals were paid for laboratory tests performed in the outpatient setting at Clinical Laboratory Fee Schedule (CLFS). Since laboratory tests are paid at CLFS, in order to allow for separate billing and payment at CLFS rates, CMS is expanding bill type 14X. 

What Does this Mean for Providers?

The expansion of bill type 14X means that hospitals that bill for laboratory services can:

  • Use bill type 14X to bill for most laboratory services
  • Continue to use bill type 13X for molecular pathology tests.  Molecular pathology tests include CPT codes 81200 through 81383, 81400 through 81408, and 81479.
  • Continue to use bill type 13X for laboratory services and other outpatient services ordered by the same physician on the same day
  • Use bill type 14X to bill for laboratory services and bill type 13X to bill for other outpatient services when the services are ordered by different physicians on the same day.

Medicare Billing Reminders

  • Code claims correctly based on services, tests and procedures performed
  • Report the CPT/HCPCS procedure codes to Medicare that most specifically matches the documentation in the medical record
  • Select and report the appropriate modifiers to the CPT/HCPCS codes on the claim according to Medicare guidelines
  • File claims within one year of the date of service for primary Medicare and MSP claims
  • Report units of service based on National Correct Coding Initiative (NCCI) and Medically Unlikely Edits (MUEs) to prevent reporting multiple services or procedures that should not be billed together because one service or procedure likely includes the other or because it is medically unlikely to be performed on the same patient on the same day
  • Have a valid Advance Beneficiary Notice (ABN) on file in order to correctly document noncovered services with the appropriate modifier, i.e. GA or GZ, which will identify the services that can be billed or not billed to the patient.

What is OPPS?

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Hospital Outpatient Prospective Payment System, or OPPS, pays for:

  • certain hospital outpatient services
  • certain hospital inpatient services covered by Medicare Part B for patients that do not have Medicare Part A coverage
  • partial hospitalization services
  • the administration and vaccination of Hepatitis B, splints, casts, and antigens by a home health agency to patients not under a home health agency treatment plan or non-terminal hospice patients

Hospital Outpatient Prospective Payment System, or OPPS, does not pay for:

  • clinical diagnostic laboratory services
  • outpatient therapy services
  • screening and diagnostic mammography

What is CLFS?

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Clinical Laboratory Fee Schedule, or CLFS, pays for hospital outpatient clinical laboratory services based on a fee schedule.  Services paid under CLFS are not subject to copays and deductibles.

More Changes Instituted in 2014

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The health and medical industry is constantly changing. It is the responsibility of the medical office to assess, analyze and implement positive changes to protect the interest of the entire organization.

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