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- Form 3: Laboratory Cost Center
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6. Form 3: Laboratory Cost Center
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or view the worksheet Form 3
- WI Laboratory Cost Center worksheet: Form 3
- WI Laboratory Cost Center worksheet:
Form 3 in PDF
format - Wisconsin Cost Center Report -
entire file in Excel
Form3 is completed in the same fashion. Look at Form3 in the Excel file. A few notes about entering information for the laboratory cost center:
- Determining relative values for laboratory tests can be a little more difficult.
- While most tests are classified by CPT codes, in some instances there are no relative values established.
- Where relative values are available through the Clinical Diagnostic Laboratory Fee Schedule, the “National Limit” value is used. If no “National Limit” or “Mid Point” values are available, the payment for the specific state (i.e.; WI) is used.
- Other relative values are based on the actual (or average) cost charged to the agency for tests sent to outside reference labs. The agency must put the price of each outside test in the Form 3 section identified as “outside Laboratory tests” (column K).
- The first step for the completion of this form is entering the average cost of outside labs (purchase price) on the table beginning at Column K30.
- Be sure to include the price for every lab test for which you have utilization data.
- The second step is to place the utilization data in Column B.
- Remember, all outside expenses must also be included on the spreadsheet “alloc-other” and/or “alloc-donate”.
