The Center for Medicare & Medicaid Service (CMS) does NOT currently have a “national” policy for the date of service (DOS) for the professional component (PC) of a diagnostic test. CMS has indicated that the DOS for the interpretation (PC) of a diagnostic test is left to the discretion of the individual contractor (i.e. carrier, MAC). Therefore, the instruction is to assign the DOS for the PC service based on the written guidelines of that given contractor.

For groups that bill for both components of the service, the claim lines must represent the accurate DOS for both the technical component (TC) and PC; filed on separate line items following the rules in this document for the TC portion and the PC portion.

McKesson Business Performance Services leadership has identified, with the assistance of some outside specialty societies (i.e. College of American Pathology), many of the carrier/MACs which have a written policy on their website and/or published in a bulletin or stated in a conference call or similar public arena their guidelines for the DOS for diagnostic test.

The following is a grid that provides recent guidelines for DOS for the given carrier/MAC:\

Lab Spotlight 1

Medicare DOES provide a “national” policy for clinical laboratory tests (i.e. those listed on the clinical lab fee schedule) AND the technical component (TC) of anatomic pathology services.

The DOS policy as specified in 42 CFR § 414.510 (IOM, 100.04, Chapter 16, Section 40.8) for either a clinical laboratory test or the technical component of physician pathology service is as follows:

  • General Rule: The DOS of the test/service must be the date the specimen was collected.
  • Variation: If a specimen is collected over a period that spans two calendar days, then the DOS must be the date the collection ended. (i.e. 24 hour urine specimen)
  • Exceptions: The following exception applies to the DOS policy for either a clinical laboratory test or the technical component of physician pathology service:

1. DOS for Tests/Services Performed on Stored Specimens:

In the case of a test/service performed on a stored specimen, if a specimen was stored for less than or equal to 30 calendar days from the date it was collected, the DOS of the test/service must be the date the test/service was performedonly if:

  • The test/service is ordered by the patient’s physician at least 14 days following the date of the patient’s discharge from the hospital;
  • The specimen was collected while the patient was undergoing a hospital surgical procedure;
  • It would be medically inappropriate to have collected the sample other than during the hospital procedure for which the patient was admitted;
  • The results of the test/service do not guide treatment provided during the hospital stay; and
  • The test/service was reasonable and medically necessary for treatment of an illness.
  • If ALL of the above bullets are NOT met, then the DOS is the date of the specimen collection.

2. If the specimen was stored for more than 30 calendar days before testing, the specimen is considered to have been archived and the DOS of the test/service must be the date the specimen was obtained from storage

These do not necessarily apply to Medicaid or Commercial carriers (including a commercial carrier that handles Medicare Replacement Plans). For these payers, please follow the written guidelines for that given payer.

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About the author

McKesson Business Performance Services offers services and consulting to help hospitals, health systems, and physician practices improve business performance, boost margins and transition successfully to value-based care.