Clinical Laboratory Test Orders that Generate More Than One Procedure

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Subject: Policy on clinical laboratory test orders that generate, or may generate, more than one procedure (CPT code)
(Composite Tests, Profile Tests, Reflex Tests, Tests with and without Pathologist Interpretation)

  1. Purpose: Certain clinical laboratory test orders, by virtue of their complexity or other requirements of the methodology, may generate more than one defined procedure (CPT code) in order for the result to be medically useful. Additionally, the individual components of every laboratory profile that includes multichannel tests will be provided to the medical staff. The physicians shall receive annual written notice including CPT codes that the laboratory uses to bill for each profile and its components and approve their use. The medical staff will make a determination and document the medical necessity of the appropriateness of ordering such tests.
  2. Policy
    1. Categories of test orders
      1. Composite tests
        Multiple procedures are performed as a result of a single test order when medically necessary for the diagnosis and treatment of patients. Tests are customarily ordered as a profile such as automated multi-channel tests deemed appropriate for the patient’s overall care.
        Refer to Appendix A
      2. Reflex tests
        Reflex tests are follow-up tests performed automatically (reflexively) when indicated by the result of the test ordered. Reflex tests are performed to quantify, clarify, confirm a result or provide important medically necessary additional information. Reflex tests are reported and may be billed as separate procedures. Tests that are not microbiologic may be ordered “without reflex” if so desired.
        Refer to Appendix B
    2. Tests available with pathologist interpretation
      Interpretative reports by a pathologist are available as standing orders approved by the Medical Executive Committee. Tests may be ordered “without interpretation” if interpretation is not desired.
      Refer to Appendix C
  3. Appendixes
    1. Composite testing
    2. Reflex testing
    3. Tests with and without pathologist interpretation

Origination: 12/05/2005

Revision: 6/2015, 9/2014, 4/2011

Review: 10/1/2015

Approval: Main Line Health Medical Executive Committee (10/2015)

Pradeep K. Bhagat, MD, Medical Director