Laboratory Compliance Question of the Week
Archive
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August 30, 2010
Question:
My question relates to getting a “complete” order for lab tests. I know there are five components of a complete order but cannot identify them all even after researching official Medicare manuals. Can you provide these components?
Answer:
The five parts for any order are as follows: patient name, order date, diagnosis (narrative or code but narrative is better), service to be performed and the physician’s signature.
If the test or service is a recurring test, then the to-and-from dates with frequency for recurring orders would also need to be documented.
If for a drug or biological, document the drug, dose, route and time increments plus any pre meds/post meds that would need to be provided.
The date the order was written is an important element as orders are only valid for a 12-month period. This is especially crucial in recurring services. Check with The Joint Commission for information about this.
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August 23, 2010
Question:
Do we have to submit documentation when we assign an unlisted code on a claim (such as 85999 discussed last week)?
Answer:
Yes, it is necessary to submit supporting documentation (e.g., procedure report) along with the claim to provide an adequate description of the nature, extent, and need for the procedure as well as the time, effort, and equipment necessary to provide the service.
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August 16, 2010
Question:
I have a follow-up to the lab question posted for August 9 regarding urine eosinophils. Why would you use 85999 rather than 81099 (unlisted urinalysis procedure)?
Answer:
The truth is that we wouldn't assign CPT 85999 if we weren’t aware that the American Medical Association (AMA) provided official guidance in this regard. We, too, think the unlisted urinalysis code would be more appropriate. Unfortunately, when there is definitive coding guidance from the AMA, MedLearn must use it whether we agree or disagree.
Why did the AMA go there with their recommendation? We really don't know. That is one for it to answer.
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August 9, 2010
Question:
What CPT code should be assigned for eosinophil stain, urine?
Answer:
According to the American Medical Association (AMA) in the October 2009 issue of CPT Assistant, the appropriate code to report is CPT code 85999 (unlisted hematology and coagulation procedure). When reporting an unlisted code to describe a procedure or service, it will be necessary to submit supporting documentation (e.g., procedure report) along with the claim to provide an adequate description of the nature, extent, and need for the procedure, as well as the time, effort, and equipment necessary to provide the service.
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August 2, 2010
Question:
A chiropractor orders laboratory tests. Can we bill the patient if Medicare denies the claim even though the lab does not have an ABN on file?
Answer:
Medicare does not cover chiropractic services except for manual manipulation. Because they are never covered, no ABN is required for laboratory services ordered by a chiropractor. The laboratory may bill the patient, however.
Here’s what the Medicare Benefit Policy Manual, Chapter 15 (Covered Medical and Other Health Services), Section 240.1.1 (Manual Manipulation) says on the topic: “Coverage of chiropractic service is specifically limited to treatment by means of manual manipulation, i.e., by use of the hands….No other diagnostic or therapeutic service furnished by a chiropractor or under the chiropractor’s order is covered. This means that if a chiropractor orders, takes, or interprets an x-ray, or any other diagnostic test, the x-ray or other diagnostic test can be used for claims processing purposes, but Medicare coverage and payment are not available for those services.”
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July 26, 2010
Question:
Can CPT code 84402 (free testosterone) be reported on the same claim with CPT 84403 (total testosterone)?
Answer:
Yes, these codes can be reported together if both tests are ordered and performed.
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July 19, 2010
Question:
When we bill more than one unit for CPT codes 87077 and 87088, can we add modifier 59?
Answer:
Yes, modifier 59 can be appended to these codes, which may be assigned to report testing on organisms recovered from multiple cultures performed on the same date of service.
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July 12, 2010
Question:
Is there any way to get paid for a test that is not medically necessary?
Answer:
Medicare beneficiaries may be billed for tests that may not be medically necessary as long as they are given and sign an advance beneficiary notice of noncoverage (ABN) before the service is provided. Non-Medicare payers may have specific rules about this.
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July 5, 2010
Question:
I have noticed that CPT code 86038 occasionally appears twice on a claim. Should it?
Answer:
CPT 86038 (antinuclear antibodies) would not be tested multiple times on a single date of service. This finding warrants further investigation.
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June 28, 2010
Question:
We are currently rechecking for each unit of blood received from the Red Cross. Can we bill 86900 more than once a day? If so, which modifier should be used, 59 or 91?
Answer:
Limit billing of CPT code 86900 (autologous blood or component, collection processing and storage; predeposited) to ABO typing of the patient. The retyping of a blood unit is for the purpose of quality checks and is an integral part of the blood matching that is performed before a unit is issued for transfusion.
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June 21, 2010
Question:
When is the appropriate time to charge CPT 86870 more than once? Is the
deciding factor, methodology, new reagent? Example: Our lab performs panel
A and B from ortho. If I use both, can I charge 86870 X 2? Both panels A
and B are performed in gel.
Answer:
By CPT code definition, you can report 86870 x 2 when you perform antibody
identification using two panels employing a single-serum technique such
as the gel method. To arrive at the correct billing unit, simply multiply
the number of panels performed by the number of techniques used. The number
of techniques used is typically the number of times you read and interpret
a panel result and document that reading.
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June 14, 2010
Question:
When a prescription is missing one or more of the five requirements (specifically diagnosis code or physician signature) and you cannot contact the office for a verbal or fax (in the case of a missing signature), do you send the patient away to have them get a corrected prescription or have them wait until the correct information can be obtained?
Our hospital would like to serve the patient and provide patient education at the same time. So, instead of having the patient bear the burden of the physician error i.e. incomplete information, we would like to go ahead and provide the service; educate the patient so they know that the physician forgot a piece of information and contact the office and get it corrected. Of course we cannot do this in the case of Medicare patients who need ABNs. That would have to be signed upfront prior to lab tests being ordered and performed if the correct information was not at hand or able to obtain.
Our thought is that we could get the information that day. We want the
patient to have a positive interaction and not a frustrating interaction.
Would this process be in compliance?
Answer:
The order needs to be a valid order to carry out the services. We realize
that there are times in which an order may not be complete, and the facility
would like to carry out the service or test and get the missing information
after the fact. However, this is not what Medicare and other third-party
payers want. What they want is a complete and valid order in place to execute
the service. There also may be some implications from state licensure and/or
the Joint Commission for doing it differently.
Suggestions: Create a fax-back form that you send to the physician's office
and, hopefully, get it returned in a timely manner. Before you send the
first fax, be sure and let your physicians know that you are implementing
this process because of incomplete orders. Also, help educate the physicians
on what is needed on the order.
If the order is sent over ahead of time, there is usually time to correct
the missing information. If the patient brings the order with him or her,
this is where we need a fax back form if the order is not complete.
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June 7, 2010
Question:
When was the last update from CMS on the lab NCDs?
Answer:
There will be a small update for the lab national coverage determination
(NCD) charts effective July 1. The update will revise noncovered ICD-9-CM
diagnosis codes for all 23 lab NCD tests, as follows:
- Delete ICD-9-CM codes V17.4 (other cardiovascular diseases) and V18.1
(other endocrine and metabolic diseases) from the list of non-covered ICD-9-CM
codes for all 23 NCDs. "Noncovered" diagnosis codes are those
never covered by Medicare.
- Add ICD-9-CM codes V17.41 (family history of sudden cardiac death), V17.49
(family history of other cardiovascular diseases), V18.11 (multiple endocrine
neoplasia syndrome), and V18.19 (other endocrine and metabolic diseases)
to the list of non-covered ICD-9-CM codes for all 23 NCDs.
The purpose of these changes is to replace four-digit diagnosis codes with more specific five-digit codes.
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May 31, 2010
Question:
CMS Transmittal 1935 notes changes to HIV screening using three new G codes:
G0432, G0433, and G0435. Are there appropriate CPT crosswalk codes related
to these G codes? Can you give any further guidance on the use of these
new codes set to be implemented July 6, 2010?
Answer:
I'm not sure if this inquirer is asking us what CPT codes were used to set the reimbursement rate for the new codes or if these codes replace CPT codes. The only information I can offer is that included in transmittal 1935 (available at https://146.123.140.205/transmittals/downloads/R1935CP.pdf).
Prior to inclusion of the above G codes on the Clinical Laboratory Fee
Schedule (CLFS), the above G codes shall be contractor-priced. For dates
of service between December 8, 2009, and April 4, 2010, unlisted procedure
code 87999 may be used when paying for these services.
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May 24, 2010
Question:
CMS Transmittal 1935 notes changes to HIV screening using three new G codes:
G0432, G0433, and G0435. Are there appropriate CPT crosswalk codes related
to these G codes? Can you give any further guidance on the use of these
new codes set to be implemented July 6, 2010?
Answer:
I'm not sure if you are asking us what CPT codes were used to set the reimbursement rate for the new codes or if these codes replace CPT codes? The only information I can offer is what is included in this Centers for Medicare & Medicaid Services (CMS) transmittal at https://146.123.140.205/transmittals/downloads/R1935CP.pdf.
Until CMS includes the above G codes on the clinical laboratory fee schedule
(CLFS), the above G codes will be contractor-priced. For dates of service
between December 8, 2009, and April 4, 2010, unlisted procedure code 87999
may be used when paying for these services.
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May 17, 2010
Question:
Would it be acceptable to order tests on patients during preadmission testing
based on the patient's history without an order from a physician?
Answer:
It is not acceptable for the laboratory to perform any testing without a physician's order or to use a patient's history as the reason for testing. Laboratory tests can only be performed when there is a written request from an "authorized person," a licensed health professional performing within the scope of his or her state license. This is a CLIA regulation. Providers who order tests must provide the laboratory with the reason for testing at the time the test is ordered.
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May 10, 2010
Question:
Can CPT 84402 (free testosterone) be reported on the same claim with 84403
(total testosterone)?
Answer:
Yes, these codes can be reported together if both tests are ordered and performed.
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May 3, 2010
Question:
We have many questions related to billing qualitative drug screens, especially
with the new G codes. Can you provide guidance on this?
Answer:
In Transmittal R653OTN, Centers for Medicare & Medicaid Services (CMS) provided what it called "special instructions" for the proper use of CPT codes 80100, 80101 and 80101QW as well as HCPCS level II codes G0430, G0430QW, G0431, and G0431QW-all codes paid under the clinical laboratory fee schedule (CLFS). The instructions provided take effect on April 1, and all affected billing staff should be made aware of the changes summarized. For this transmittal, go to http://www.cms.hhs.gov/Transmittals/downloads/R653OTN.pdf. For the related provider-information memo, go to http://www.cms.gov/MLNMattersArticles/downloads/MM6852.pdf.
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April 26, 2010
Question:
We are currently rechecking for each unit of blood received from the Red
Cross. Can we bill 86900 more than once a day? If so, which modifier should
be used, 59 or 91?
Answer:
Limit billing of CPT code 86900 to ABO typing of the patient. The retyping of a blood unit is for the purpose of quality checks and is an integral part of the blood matching that is performed before a unit is issued for transfusion.
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April 19, 2010
Question:
Regarding end-stage renal disease (ESRD) patients, when would Q4081 be
used? Would J0885 ever be appropriate for an ESRD patient on dialysis? Also,
when should code J0886 be used?
Answer:
As the descriptor states, Q4081 should be used for 100-unit increments of epoetin alfa injections for ESRD patients on dialysis. Code J0886 should be used to bill 1,000-unit increments for ESRD patients on dialysis. For non-ESRD patients, report J0885 that are receiving 1,000 units of Epogen/Procrit.
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April 12, 2010
Question:
For the following scenario, what CPT code can the outpatient office charge
and for what diagnosis, and what can the hospital lab charge for and with
what diagnosis?
Patient (ICD-9 code 427.31 [atrial fib]) and V58.61 on coumadin) is seen
in a physician's office (waived or moderate CLIA certificate) that is part
of a critical access hospital and has a prothrombin INR done (finger stick)
with a waived instrument to determine if her dosage needs to be changed
(ICD-9 code V58.83). The result is >5 INR (very high). To verify the
accuracy of the high result (standing order for all INR >5 to be repeated
by standard lab method at the hospital lab), the hospital employee in the
physician office collects a tube of blood for a PT with INR via venipuncture
and sends it to the main hospital laboratory (CAP-inspected lab) for a prothrombin
time.
Answer:
For Medicare billing, CPT codes 36415 (venipuncture) and 85610 (protime) can be charged. No modifier is applicable. CPT 36591 (collection of blood specimen from a completely implantable venous access device) should not be used to report a venipuncture.
Since the hospital lab performed the protime that resulted, it would bill it to Medicare while the physician office would report the venipuncture only. The ICD-9 codes assigned must reflect information in the patient's medical record.
According to the narratives in the national correct coding initiative (CCI) policy, if a patient has an abnormal test result and repeat performance of the test is done to verify the result, the test is reported as one unit of service rather than two.
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April 5, 2010
Question:
How should we be charging for the multiple stains under 88313 and 88342? Per the CPT code book these codes are both an "each," so no modifier should be added. We have four accounts that are hitting a MUE at Medicare, three for 88313 and one for 88342.
Answer:
The unit for reporting 88312-88314 is the specimen. Do not report the number of slides stained. As evidenced by the reports you provided to us, only one silver stain was performed on the tissue submitted for light microscopy. There should be only one associated charge.
The unit for reporting both 88342 and 88346 is "each antibody." No modifier is required, and the number of units you are charging appears correct based on documentation of antibody testing you provided.
The Centers for Medicare & Medicaid Services does not publish the medically unlikely edits (MUEs) for any of the codes above. You can review claim remittance advice data to determine the units allowed.
There is another issue in the documentation provided that warrants further investigation. The surgical pathology gross and microscopic exam code reported on one of the two examples you provided is CPT 88300 (level I, surgical pathology, gross examination only instead of CPT 88305 (level IV, surgical pathology, gross and microscopic exam), the applicable code. No special stains or immunohistochemistry or immunofluorecent studies would be indicated for a study reported with a level I surgical pathology exam.
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March 29, 2010
Question:
One of our doctors used code V81.2 (cardiac screening) to support 80061 (lipid test). There were also other tests included on the outpatient claim with other diagnosis codes to support them. However, we got a denial for all of the tests stating that cardiac screening could be used only once every five years. But we only used V8.12 for the lipid test (per our local coverage determination), not for the CBC, UA or any other test. We don't understand why all of the tests are being denied when there is other significant support.
Answer:
We do not have sufficient information to tell you the reason for the denial.
It may be that the patient had one or more of the screening tests within
the last 59 months, and/or there are other issues that would only be apparent
from reviewing medical records, the actual claim and the denial you received.
We would encourage you to review The Guide to Medicare Preventive Services
for Physicians, Providers, Suppliers and other Health Care Professionals
at www.cms.hhs.gov/MLNProducts/downloads/mps_guide_web-061305.pdf.
The guide includes the coding and billing requirements for cardiovascular
screening blood tests relative to the submission of both the UB-04 claim
and CMS-1500 claim. It also includes reasons for claim denial and other
resources you may find helpful.
The ICD-9 CM codes to support the medical necessity of the cardiovascular
screening blood tests are V81.0, V81.1 and V81.2.
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March 22, 2010
Question:
The description for code 82272 (for blood occult screening) indicates 1-3 simultaneous determinations, performed for other than colorectal neoplasm screening. We are trying to understand the meaning of simultaneous.
Answer:
According to CPT coding guidelines, the lab should be billing one time for the three specimens that are submitted by the patient using CPT code 82272.
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March 15, 2010
Question:
How do I code for array-based evaluations of more than 500 codes?
Answer:
The American Medical Association established CPT codes 88384-88386 so that
providers may report array-based evaluation of multiple probes. These codes
were added to the anatomic pathology subsection because they were primarily
intended to be used in the processing of specimens typically analyzed by
traditional surgical and cytopathology techniques to include the chromosome
analysis of blood.
Given that there is no code for the performance of an array-based evaluation
of >500 probes, 88399 is applicable. Be sure to submit supporting documentation
(e.g., procedure report) along with the claim to provide an adequate description
of the nature, extent, and need for the procedure and the time, effort,
and equipment necessary to provide the service.
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March 8, 2010
Question:
The American Medical Association CPT guidelines say that 36430 is included
in the surgical CPT procedure. So, if a patient has surgery in a hospital
and then has postoperative blood loss anemia requiring a blood transfusion,
can this be charged separately? Also, I'm not sure what "unrelated
to the surgery" means in the AMA CPT guidelines.
Answer:
In the outpatient hospital setting, if the blood administration is a separate and distinct procedure that is provided on the same day as a surgical procedure, report the transfusion with modifier 79.
Global surgery rules do not apply to hospitals (according to the policy narratives in the National Correct Coding Initiative Policy Manual, version 15.3). For physicians, "unrelated to the surgery" means any service other than routine postoperative care. (For example, this might be an evaluation and management (E&M) service for an acute illness that is unrelated to the surgery.)
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March 1, 2010
Question:
You mentioned a new GX modifier last week. I am not familiar with this
modifier. Can you provide Medicare guidelines for using it?
Answer:
The modifier GX is a voluntary modifier to be used when a test is not covered (never covered) for statutory reasons, and you have issued an advance beneficiary notice (ABN) informing the patient of his/her financial liability. More on this and other ABN-related instructions can be found at http://www.cms.hhs.gov/Transmittals/downloads/R1840CP.pdf.
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February 22, 2010
Question:
Do you know whether any changes will be made to the ABN to accommodate
the new GX modifier?
Answer:
Modifiers are used for claims processing and are not included on the ABN form. CMS-R-131, the current ABN form, services to fulfills both mandatory and voluntary notice functions. We are unaware of any proposed changes to the CMS-R-131.
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February 15, 2010
Question:
One of our doctors used the V8.12 (cardiac screening) to support 80061
(lipid test). There were also other tests included on the outpatient claim
with other diagnosis codes to support them. However, we got a denial for
all of the tests stating that cardiac screening could be used only once
every five years. But we only used V8.12 for the lipid test (per our local
coverage determination), not for the CBC, UA or any other test. We don't
understand why all of the tests are being denied when there is other significant
support.
Answer:
We do not have sufficient information to tell you the reason for the denial.
It may be that the patient had one or more of the screening tests within
the last 59 months, and/or there are other issues that would only be apparent
from reviewing medical records, the actual claim and the denial you received.
We would encourage you to review The Guide to Medicare Preventive Services
for Physicians, Providers, Suppliers and other Health Care Professionals
at www.cms.hhs.gov/MLNProducts/downloads/mps_guide_web-061305.pdf.
The guide includes the coding and billing requirements for cardiovascular
screening blood tests relative to the submission of both the UB-04 claim
and CMS-1500 claim. It also includes reasons for claim denial and other
resources you may find helpful.
The ICD-9 CM codes to support the medical necessity of the cardiovascular
screening blood tests are V81.0, V81.1 and V81.2 so we are assuming that
you did report V81.2 and not V8.12 which is an invalid code.
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February 8, 2010
Question:
Can the pathologist bill codes 88387 and 88388 as professional billing,
or are these technical codes only? Our pathologists work with the lab techs
and show them exactly where and how much tissue is needed for the cytogenetic
studies.
Answer:
CPT 88387 and CPT 88388 have a professional and technical component. Both the facility and the pathologist can report these codes. You can see this on the Medicare physician's fee schedule, which includes the global, professional and technical component reimbursements.
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February 1, 2010
Question:
I have a question on how to interpret the new CMS update related to the new G codes for the laboratory. Under the Background section, CMS says the following; the two statements seem to contradict each other.
New test code G0431 is a direct replacement for CPT Code 80101. However, CMS is delaying this replacement until April 1, 2010.
Similarly, from January 1, 2010 through March 31, 2010, when performing a qualitative drug screening test for a single class of drugs, regardless of the testing methodology, those clinical laboratories that do not require a CLIA certificate of waiver should bill new test code G0431. Those clinical laboratories that do require a CLIA certificate of waiver should continue to utilize CPT Code 80101QW.
Is G0431 to be used effective January 1 or April 1?
Answer:
The article you referenced is MLN Matters Number SE1001. It is available at http://www.cms.hhs.gov/MLNMattersArticles/downloads/SE1001.pdf.
HCPCS level II code G0431 was effective on January 1, 2010, and is a valid code for reporting. CMS's implementation of the requirement for all facilities to report the code is what is delayed. For now, CMS tells providers with a CLIA certificate of waiver to report CPT 80101QW. All other laboratory providers must report G0431 without delay.
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January 25, 2010
Question:
Does a lab with a CLIA certificate of accreditation need to use the QW
modifier, or is that just for the labs with a CLIA certificate of waiver
(COW)?
Answer:
To ensure that Medicare and Medicaid only pay for laboratory tests categorized
as waived complexity under CLIA in facilities with a CLIA COW, all entities
holding a COW must use the QW modifier to avoid claim denial.
Hospital labs typically hold CLIA certification that allows them to perform
any level of testing. They do not need to report modifier QW to show they
are performing testing within the scope of their license.
For an authoritative resource on this, go to http://www.cignagovernmentservices.com/NetCourses/Printable_NetCourses/Modifiers/ModifiersDoc.html.
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January 18, 2010
Question:
In regard to chemistry codes, does the following rule still apply? At least
three components of a complete blood count must be ordered for a comprehensive
code to be used.
Answer:
Before the American Medical Association revised the hematology section of CPT in 2003, bundling three or more parameters was acceptable. However, the bundling mandate has not applied since the AMA revised the definitions of 85025 and 85027.
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January 11, 2010
Question:
Is it considered incorrect coding to use 87077 instead of 87088 for ID
of urine isolates?
Answer:
CPT codes 87077 and 87088 are distinct codes with unique definitions. In the case of the Medicare program, there are no correct coding initiative (CCI) edits for either of these codes or coding combinations. Both codes are reportable to Medicare and could, by definition, be used to report urine isolate identification procedures.
Select the code(s) that accurately describe the service(s) you provide and report them in accordance with correct coding policies and in consideration of guidelines included in the Medicare national coverage determination (NCD) for urine cultures, bacterial (190.12) at http://www.cms.hhs.gov/center/clinical.asp. (Click on the last bullet under Coverage for the index.) These NCDs are updated quarterly. Proposed changes to the policies may or may not provide further directives relative to reporting 87077 and 87088.
For non-Medicare patients, check the American Medical Association's coding guidance in the preamble to the microbiology section of the 2010 CPT codebook.
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January 4, 2010
Question:
Are blood transfusions considered part of, or included in, the surgical
package? Or can a blood transfusion given after surgery be charged?
Answer:
The CPT surgical package, as defined in the surgery guidelines of the American Medical Association's CPT code book, does not include transfusions. Follow-up care for therapeutic surgical procedures includes only care that is usually a part of the surgical service. Blood administration (transfusions) unrelated to the surgery or a result of complications, exacerbations, recurrence or the presence of other diseases or injuries requiring additional services should be separately reported.
Be aware that charges for blood product processing on an outpatient claim will not be paid unless the claim also includes a charge for blood administration.
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December 28, 2009
Question:
Must a QW modifier be attached to the codes for all waived tests?
Answer:
Most but not all CLIA-waived tests require the attachment of modifier QW. According to the Centers for Medicare & Medicaid Services, tests with the following CPT codes do not require a QW modifier to be recognized as a waived test: 81002, 81025, 82270, 82272, 82962, 83026, 84830, 85013, and 85651.
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December 21, 2009
Question:
I heard there was a new modifier for use with ABNs. Do you have information
about this?
Answer:
Yes, the Centers for Medicare & Medicaid Services (CMS) issued Transmittal 1840 on October 29, 2009 in which it issued a revised GA modifier and a new GX modifier. It updated these two HCPCS Level II modifiers to allow the voluntary use of liability notices to be distinguished from the required use of them. The agency also made significant changes (such as deleting old sections and adding new sections) to several chapters in the Medicare Claims Processing Manual. The transmittal can be found at http://www.cms.hhs.gov/Transmittals/downloads/R1840CP.pdf.
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December 14, 2009
Question:
What are the latest changes made by CMS to the lab coverage determinations?
Answer:
The quarterly changes to the Medicare edit module, which take effect for services provided on and after January 1, 2010, relate to serum iron studies and gamma glutamyl transferase (GGT). Another change relates to a new effective date for prothrombin time, serum iron studies, and GGT. All of this information can be found in the related transmittal at http://www.cms.hhs.gov/Transmittals/downloads/R1847CP.pdf
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December 7, 2009
Question:
I am following up on last week's question and answer. Should the tests
be bundled into the panel before it leaves the hospital and is submitted
to the Medicare payer? Or should we submit individual tests and let Medicare
do the bundling after it determines which option (bundled or unbundled)
represents the lowest cost?
Answer:
There is no longer any mandate for a lab to bundle chemistry assays, for example, and report the organ or disease-oriented panel codes. Reporting of the panel codes is simply a coding option.
Bundling/unbundling requirements apply to Medicare claims processing. Specifically, CMS established the national correct coding initiative (NCCI) edits and national coverage determinations (NCD) to promote correct coding and prevent inappropriate payments.
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November 30, 2009
Question:
It's my understanding that unless a physician orders all of the tests included
in a defined panel, the tests must be billed individually. For example:
if a physician specifies on the order, a WBC (85048), H (85014) and H (85018),
and PLT (85049) we would bill using the four listed CPT codes instead of
85027 (CBC, which includes the above tests and RBC). I recently heard that
if more than 50 percent of the tests in a panel are ordered, then the panel
can be billed instead of the individual tests. I can't seem to find documentation
to support that idea. Can you help?
Answer:
Your understanding is correct. Unless a physician orders all of the tests included in a CPT-defined panel, the tests ordered must be billed individually to avoid prosecution under the False Claims Act.
According to the Department of Health & Human Services Office of Inspector
General's (OIG) Compliance Program Guidance for Clinical Laboratories, laboratory
policies should ensure that the CPT or HCPCS code that is used to bill accurately
describes the service that was ordered and performed. Laboratories cannot
alter the physician's order in any way-either increasing or decreasing the
number of services performed without the express consent of the ordering
physician or other authorized individual. To ensure code accuracy, laboratories
should require that individuals with technical expertise in laboratory testing
review the appropriateness of the codes before the claims are submitted.
Intentional or knowing upcoding (i.e., the selection of a code to maximize
reimbursement when such code is not the most appropriate descriptor of the
service) could violate the False Claims Act and/ or other civil laws, and
criminal law.
Hematology tests that are grouped and performed on an automated basis are
classified as panels. There are two panel tests included in the hematology
section of CPT. See CPT 85025 and CPT 85027.
By CPT definition, a complete blood count consists of measuring a blood specimen for levels of hemoglobin, hematocrit, red blood cells, white blood cells, and platelets. If a physician orders only three or four of these parameters, you may not report a complete blood count CPT. Report the individual analyte codes.
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November 16, 2009
Question:
I know that CMS proposed new codes for qualitative drug screens. Has CMS
issued these codes yet?
Answer:
Yes, CMS issued the final HCPCS Level II codes, which take effect January 1, 2010, and there are two additions defining qualitative drug screening:
G0430 Drug screen, qualitative; multiple drug classes other than chromatographic
method, each procedure
G0431 Drug screen, qualitative; single drug class method (e.g., immunoassay,
enzyme assay), each drug class
The above description of G0430 differs slightly from the description of the American Medical Association's (AMA) CPT® code 80100, while G0431 appears to replace the 80101 for billing to Medicare. As you may know, care must be taken to ensure correct selection of CPT or HCPCS by matching the procedure or kit methodology to the accurate code.
MedLearn laboratory consultants believe that lab coders will struggle with correlating the correct code to the new test methodologies.
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November 9, 2009
Question:
Regarding last week's answer, V72.6 is invalid as of 10/01/08. The code
requires a fifth digit.
Answer:
You are correct that the codes changed on October 1. See below for descriptons.
V72.60 describes lab exam, unspecified. Because we did not have any diagnostic
information at all on the patient described in last week's case, we would
recommend V72.60 as the answer.
Others in this series include: V72.61-antibody response exam, V72.62-lab exam ordered as part of a routine general medical exam, V72.63-prerocedural lab exam, and V72.69-other lab exam.
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November 2, 2009
Question:
Has the AMA issued the 2010 CPT codes yet? If so, what do they look like
for labs?
Answer:
There are 17 revised codes, 15 new codes and two deleted codes in the pathology and laboratory section. The majority of the revisions (10 of the 17) have been made in the chemistry section. One to three new codes can be found in several of the sections. Be sure to get a copy of the new 2010 CPT manual to ensure accurate code assignments.
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October 26, 2009
Question:
I have a question regarding the use of V codes such as V72.6. A hospital has a lab, and the patients come from area doctors' offices, and the registration clerk or lab tech takes the requisition without a diagnosis. We are being told by our patient accounts office to use code V72.6.
Is this compliant when no diagnosis is given or several attempts to call
or fax the doctor's office results in no answer. We do not turn away patients
but according to what I have read, lab slips require a diagnosis by the
ordering physician. What would the proper thing to do?
Answer:
Based on information from Section IV--Diagnostic Coding and Reporting Guidelines
for Outpatient Services, Coding Clinic, Fourth Quarter 2008 (10/1/2008,
Pages 307 to 311, effective with discharges: October 1, 2008), we would
say that it is appropriate to use V72.6. Note especially the third bullet
below.
- The appropriate code or codes from 001.0 through V89 must be used to identify
diagnoses, symptoms, conditions, problems, complaints, or other reason(s)
for the encounter/visit.
- The selection of codes 001.0 through 999.9 will frequently be used to
describe the reason for the encounter. …
Under subtitle of "patients receiving diagnostic services only,"
it says: … For encounters for routine laboratory/radiology testing
in the absence of any signs, symptoms, or associated diagnosis, assign V72.5
and V72.6. If routine testing is performed during the same encounter as
a test to evaluate a sign, symptom, or diagnosis, it is appropriate to assign
both the V code and the code describing the reason for the nonroutine test.
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October 19, 2009
Question:
When a physician orders a renal function panel (CPT code 80069) and a liver
failure panel (CPT code 80076), we receive a rejection because an albumin
is contained in each of the panels. How are we supposed to bill this?
Answer:
It is not appropriate to bill the panel code for two panels performed on a single specimen when the panels contain duplicate analytes as this would result in double billing (in this case the albumin would be included in reimbursement for both of the CPT codes). Laboratories should work with physicians to order only the tests that are medically necessary. When multiple tests are needed, the physician should select the most appropriate organ / disease panel and then select only those additional analytes that are deemed medically necessary. Most laboratory order-entry systems can be programmed to alert physicians or staff when they order panels that are duplicate testing of a single analyte.
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October 12, 2009
Question:
We perform guiac testing on stools, and sometimes we receive two or three
stool specimens from different times but within the same day, perform the
testing and bill each (we do not use cards). We receive a rejection on one
or two of the specimens (we use CPT code 82270). How are we supposed to
bill these? Maybe modifier 91?
Answer:
The definition for CPT code 82270 is "blood, occult, by peroxidase activity (e.g., guaiac), qualitative; feces, consecutive collected specimens with single determination, for colorectal neoplasm screening (i.e., patient was provided three cards or single triple card for consecutive collection)".
The reference to "card" is provided in parenthesis as an example of how the specimen is most frequently submitted, but this reference does not limit the use of the code to this method of performing the FOBT. The key term in this description is "consecutive collected specimens with single determination." CPT code 82270 is billable with a unit of 1 as indicated in the medically unlikely edits table of limitations.
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October 5, 2009
Question:
Would you please clarify the answer to the September 21 question? As I
understand it, for a urine culture with isolation of two organisms requiring
ID and MIC sensitivities we can charge:
- 87086 for the culture
- 87088 x 2 for each organism identified on our automated system
- 87186 x 2 for each organism MIC sensitivity performed on our automated
system
Answer:
Yes. The recommendation is based on the guidance provided by the Centers
for Medicare & Medicaid Services in the Laboratory NCD Manual
under Additional Coding Guidelines.
190.12 - Urine Culture, Bacterial
1. Specific coding guidelines:
a. Use CPT 87086 Culture, bacterial, urine; quantitative, colony count where a urine culture colony count is performed to determine the approximate number of bacteria present per milliliter of urine. The number of units of service is determined by the number of specimens.
b. NOT APPLICABLE TO THIS QUESTION
c. Use CPT 87088 where identification of morphotypes recovered by quantitative culture or commercial kits and deemed to represent significant bacteriuria requires the use of additional testing, for example, biochemical test procedures on colonies. Identification based solely on visual observation of the primary media is usually not adequate to justify use of this code. The number of units of service is determined by the number of isolates.
d. Use CPT 87184 or 87186 where susceptibility testing of isolates deemed to be significant is performed concurrently with identification. The number of units of service is determined by the number of isolates. These codes are not exclusively used for urine cultures but are appropriate for isolates from other sources as well.
e. Appropriate combinations are as follows: CPT 87086, 1 per specimen with 87088, 1 per isolate and 87184 or 87186 where appropriate.
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September 28, 2009
Question:
I am looking for information on the CAH lab update that says we can now
bill non-patients as a bill type 131. Can you please share this with me?
Answer:
For critical access hospitals (CAHs), the definition of an outpatient was redefined and some services previously defined as non-patient have been moved to outpatient status. Now only a true non-patient sample is reported on the 141 type of bill (TOB). This standardizes the definition of non-patient for outpatient prospective payment system hospitals and CAHs. One of the Medicare memos summarizing this (see below) specifically say, "For non-patients, tests are still to be billed on the Type of Bill (TOB) 14X and such claims will be paid based on the clinical laboratory fee schedule."
Be sure to read Transmittal 1782 (issued July 30) and MM6395 at http://www.cms.hhs.gov/Transmittals/downloads/R1782CP.pdf provider-information and http://www.cms.hhs.gov/MLNMattersArticles/downloads/MM6395.pdf.
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September 21, 2009
Question:
Can a laboratory bill CPT code 87077 for urine definitive identifications?
Or are urine identifications limited to 87088?
Our lab was recently billed with a urine culture (87086), both CPT codes
87077 (definitive) and 87088 (presumptive) identifications. A MedLearn publication
states that "NCD lacks instructions to use 87076 and 87077, therefore
assume that providers should not report the codes when billing for identification
of isolates from a urine culture." It also states that "it is
appropriate to code 87088 for each isolate requiring definitive identification
to the genus and species level."
Answer:
We do not recommend that a laboratory bill for presumptive identification
of urine isolates by reporting 87088 nor do we recommend that 87077 be assigned
for definitive identification of urine isolates.
We do recommend that a laboratory in the acute hospital setting bill for
urine culture plus colony count with CPT 87086 and the definitive identification
of urine isolates with CPT 87088.
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September 14, 2009
Question:
May an Advanced Beneficiary Notice (ABN) be utilized to bill the beneficiary
for services denied due to an MUE?
Answer:
According to the Centers for Medicare & Medicaid Services, a provider/supplier cannot bill the beneficiary for services denied due to a medically unlikely edit (MUE), which is an initial determination based on a coding denial, not a medical necessity denial. By statute an advance beneficiary notice (ABN) may be applied only if the initial determination on a claim results in a denial due to medical necessity. If a provider appeals an MUE denial and some units of service are denied as not medically necessary, the provider should NOT apply an ABN to bill the beneficiary. An appeal is not an initial determination, and by statute the ABN provision only applies to the initial determination.
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September 7, 2009
Question:
A patient who has a blood disorder receives transfusions multiple times a week. The blood must be checked for CMV. The patient can receive multiple units in one day. Code 86644 is based on the number of units of blood received. We use modifier 91 and identify the number of units as 3.
Medicare is disallowing our number of units, saying that it is considered highly unlikely when a normal, one-time reportable result is all that is required.
Code 86644 is not listed on the current MUE listing. So where else would
we need to review the edit code?
Answer:
CPT code 86644 is intended for diagnostic use in determining patient status and is not the appropriate billing for testing of the blood product for transfusion. The facility would report the appropriate P-code representing a CMV- HCPCS.
CMS instructs providers to be familiar with the CCI edits that apply to the billing of blood and blood products. Modifier 91 is specific to the repeat testing of subsequently collected patient specimens and would not be applicable to the blood product. Instead of billing separately for testing by billing 86644 bundle the cost of testing to the charge for the blood product represented by P9051, P9058, etc.
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August 31, 2009
Question:
Can a laboratory bill CPT code 87077 for urine definitive identification,
or are they limited to 87088?
Our lab recently billed both CPT codes 87077 (definitive) and 87088 (presumptive)
identifications with a urine culture (87086). The MedLearn literature states
that "NCD lacks instructions to use 87076 and 87077, therefore assume
that providers should not report the codes when billing for identification
of isolates from a urine culture." The literature also states that
"it is appropriate to code 87088 for each isolate requiring definitive
identification to the genus and species level." If you could help me
with this question, I would appreciate it.
Answer:
We do not recommend that a laboratory bill for presumptive identification
of urine isolates by reporting 87088. We also do not recommend that definitive
identification of urine isolates be reported with CPT 87077.
We do recommend that a laboratory in the acute hospital setting bill for
urine culture and colony count with CPT 87086 and the definitive identification
of urine isolates with CPT 87088. This recommendation is based on information
in the laboratory national coverage determination for bacterial urine (policy
190.12). This is available at http://www.cms.hhs.gov/mcd/index_section.asp?from2=index_section.asp&ncd_sections=40&,
Search under Urine, Bacterial.
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August 24, 2009
Question:
Periodically our lab will run a test (87799) for the Polyomavirus (BK/JC
virus). The patient has no signs or symptoms, and the clinic is basically
screening the transplant patient for blood levels. What ICD-9 code would
be used? In another scenario the blood creatinine is elevated, what ICD-9
code would be used?
Answer:
For the transplant patient who has received a donor organ, we believe that the intent of the physician is to screen "post potential exposure." However, the laboratory would need to work with the treating / ordering physician to obtain the documentation to support use of this indication.
You could not assign the ICD-9 code based on an elevated creatinine unless the treating / ordering physician provided a diagnosis related to this result. If you mean that the physician provided an indication of "elevated creatinine" as the supporting diagnosis for performance of the BK/JC virus, we would say that additional information is needed to better apply the diagnosis code (e.g., "such as suspected rejection due to …").
Based on the information you provided, the following diagnosis codes would
be assigned:
V73.89 Screening exam for viral disease for the screening of the BK/JC virus
794.4 Nonspecific abnormal results of function study of kidney for the creatinine
level being abnormal
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August 17, 2009
Question:
Have a lot of new diagnosis codes been added to the lab NCDs for the next
quarter being that it is the start of the government's fiscal year?
Answer:
Yes, a number of ICD-9-CM diagnosis codes have been added to the laboratory national coverage determinations (NCDs). In fact, 14 of the 23 lab NCDs have new diagnosis codes for the quarter beginning on October 1. This list can be found in Transmittal 1766 (July 10) at http://www.cms.hhs.gov/transmittals/downloads/R1766CP.pdf and in provider-information memo MM6548 at http://www.cms.hhs.gov/mlnmattersarticles/downloads/MM6548.pdf.
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August 10, 2009
Question:
My lab director reviews monthly quality control but says he does not have
to sign. This is not what the regulations of COLA specify. Which regulation
can I give him to document his responsibilities as director?
Answer:
Certain chapters of the Medicare program's State Operations Manual provide information related to CLIA survey procedures. You may use these chapters and others to compare the Medicare requirements to the COLA requirements for the medical director. The main link to all manuals is http://www.cms.hhs.gov/Manuals/IOM/list.asp; scroll down to Publication 100-07-State Operations Manual. For a direct link to Chapter 6, which covers special procedures for laboratories, go to http://www.cms.hhs.gov/manuals/downloads/som107c06.pdf.
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August 3, 2009
Question:
We received a Medicaid denial for 86903 plus modifiers x 5 units. Our payer's
remittance advice states that the benefits have been exceeded. Can you suggest
how they can get paid for this?
Answer:
This CPT code is frequently associated with incorrect units of service
being reported on the claim. Our first recommendation is to review the record
and ensure that the number of billed units of service represents the number
of units actually screened and is not the total number of antigens X units
screened.
Second, the CPT code 86903 is not on the published list of medically unlikely
edits (MUEs), but not all codes are published. Before making any assumptions,
we would need to review the edit code and exact language for the edit.
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July 27, 2009
Question:
Your June 15, 2009, laboratory question addressed the topic of whether
a lab can get paid for follow-up testing on cultures. In the answer you
said that "labs have gotten into trouble…by billing for the sensitivity
test at the time the culture is ordered. For most cultures, you will know
within 24-48 hours if a sensitivity test is indicated."
I circulated this answer to others on our staff, who disagree with the answer,
saying that the date of service for lab procedures should always be the
date of the specimen collection, unless the testing being done is substantially
later (e.g., more than 30 days), such as for pathology consults, receptor
testing, etc.
Can you provide a follow-up on this?
Answer:
Some clarity to MedLearn's response is obviously needed. It is correct
that the date of service for the sensitivity should correlate to the date
of specimen collection and not the date the sensitivity is set-up or the
date the sensitivity is complete.
The intent of our June 15 answer was to communicate that an order-entry
explosion that autogenerates a charge for sensitivity at the time a specimen
is accessioned for culture is inappropriate. Based on our experience, this
is a problem as labs link charges for culture, identification and sensitivity
to a parent code that explodes at the time of specimen accession in the
laboratory. This type of explosion results in the billing of identification
and sensitivity procedures when a culture is reported as no growth or negative
for pathogen.
To accurately bill for the additional procedures of identification and sensitivity
we recommend separate order-entry procedures for each billable procedure.
However, there must be a process that links the order entry for identification
and sensitivity back to the date of service associated with the specimen
collection date. Most - but not all - information systems are programmed
to automate this process for microbiology processing.
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July 20, 2009
Question:
Can an inpatient receive outpatient dialysis? If so, are the lab tests
included in the composite rate?
Answer:
During an inpatient stay, Medicare covers the cost of dialysis via the DRG system for those patients which require dialysis. All lab tests are included in the DRG payment. The composite rate for dialysis does not apply.
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July 13, 2009
Question:
We have a large oncology practice whose physicians like to order a hemogram
and manual differential. Is it appropriate to charge two separate CPT codes-one
for the hemogram (85027) and one for the manual diff (85007)?
Answer:
Yes. In the case of an oncology practice, medical indications support the need for a manual differential, allowing for visual review of cells and notation of changes or anomalies. When the oncologist writes the order for CBC with manual differential, the laboratory has supporting documentation for the billing of 85007 and 85027.
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July 6, 2009
Question:
My question refers to your answer in the June 29 laboratory question. If the billable CPT remains 85025 instead of 85027 + 85007 when an automated differential can't be reported and a manual differential must be performed, when is it ever acceptable to bill 85027+85007?
If 85025 is credited (because of instrument flags that suggest the automated
differential is inaccurate), why wouldn't it be reasonable to bill 85027+85007,
if that is the only way a CBC and WBC differential can be reported?
Answer:
Laboratories would bill for the procedures ordered by the physician and performed by the laboratory. If the physician orders a CBC with manual differential, then the laboratory would bill 85007 and 85027.
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June 29, 2009
Question:
If a physician orders a CBC (85025) and the auto differential is flagged
on the hematology analyzer, the auto differential is not reported and a
manual differential is performed and reported. Can the lab bill for the
manual differential (85007) and hemogram (85027) in place of the 85025?
Or is this considered a quality control issue?
Answer:
The validation of flagged differential values by performance of manual differential or slide review is considered a quality assessment step. Labs should review the steps recommended by the instrument manufacturer for resolution of differential flags and follow the appropriate protocol. However, the billable CPT remains 85025. Quality assessment is an inherent cost calculated into the procedure charge.
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June 22, 2009
Question:
As a follow-up to last week's question and answer, how would we bill confirmatory
testing for antibiotic sensitivity such as D-test or ESBL?
Answer:
The combination of sensitivities performed are represented by different CPT codes that, when reported, will trigger a CCI edit. It would not be appropriate to append modifier 59 to the code pair for the minimum inhibitory concentration (MIC) (87186) and disk agar sensitivity (87181) or enzyme detection (87185). When performing multiple sensitivities, bill only for the most extensive procedure that provides definitive result when that testing is performed on a single infectious agent. When performed as a confirmatory test, the cost of the D-test and ESBL should be bundled to the MIC.
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June 15, 2009
Question:
Can a lab get paid for follow-up testing on cultures?
Answer:
Many labs do not bill for the follow-up testing on cultures. However, these are reimbursable codes, and a lab is essentially forgoing revenue it earned if it does not accurately and appropriately bill for procedures it performs. Labs have gotten into trouble, though, by billing for the sensitivity test at the time the culture is ordered. For most cultures, you will know within 24-48 hours if a sensitivity test is indicated. This is well within the billing office's billing time span.
When a culture isolate requires the performance of antimicrobial susceptibility studies (sensitivity studies), assign the appropriate code or codes (87181-87190) in addition to codes describing the presumptive/ definitive culture and/or additional culture typing methods already performed.
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June 8, 2009
Question:
If a doctor writes an order for a renal profile but the lab does not have
such a panel, what should be done to resolve this? Ordering the tests they
specify manually adds up to a lot more money than a panel, but ordering
a panel when all the tests are not ordered or needed isn't right either.
Answer:
The physician is requesting a panel defined by the American Medical Association
(AMA). The Centers for Medicare & Medicaid Services (CMS) has established
payment for the CPT that is defined to include the components of that panel.
This would not be a customized panel unless the physician defined components
other than those listed by the AMA for the renal function panel. When the
laboratory performs the AMA-specified components, they may code and bill
separately. However, MedLearn recommends the lab submit the appropriate
CPT code for the panel. Regardless of whether the laboratory submits individual
CPT code or the panel code, the CMS regional payer will evaluate the test
for medical necessity and determine the payment rate.
In this case, we would recommend billing with CPT 80069 which includes the
following:
albumin (82040); calcium, total (82310); carbon dioxide (bicarbonate) (82374);
chloride (82435); creatinine (82565); glucose (82947); phosphorus inorganic
(phosphate) (84100); potassium (84132); sodium (84295); and urea nitrogen
(BUN) (84520).
The above recommendation is based on information from the Medicare Claims Processing Manual, Chapter 16, Section 90.2 at http://www.cms.hhs.gov/manuals/downloads/clm104c16.pdf.
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June 1, 2009
Question:
In the answer to the May 11 question, you said that we cannot bill for
the use of the blood warmer. My question is this: Can we bill for the tubing
that is used to warm the blood during transfusion?
Answer:
Providers may chose to bill or bundle. If the tubing is the routine infusion set used for blood administration, we recommend that you bundle. But if the tubing is specific to the equipment used when the patient's antibody screen / identification indicates the need for use of a blood warmer, we recommend billing with a 27X revenue code. As the set-up for the blood warmer would not be used 100 percent of the time that transfusion CPT code 36430 is billed, providers will probably not want to bundle this particular cost.
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May 25, 2009
Question:
Is it appropriate to charge an IV Lasix with 96374 (therapeutic, prophylactic,
or diagnostic injection (specify substance or drug); intravenous push, single
or initial substance/drug) along with code 36430 (transfusion, blood or
blood components)? Medicare has these two charges as being allowed with
a modifier (according to the CCI edit). Do you feel it is appropriate for
us to charge the Lasix push with the blood transfusion by adding the 59
modifier? The department states that Lasix is routinely given to patients
at the time of the transfusion but not in all cases.
Answer:
The IV push of Lasix is billable in addition to the blood transfusion represented by 36430 if documentation in the medical record supports medical necessity. Your question indicates that you have an appropriate physician order, so we must assume this means that the request for Lasix administration is supported by a diagnosis that indicates it is medically necessary for this patient. It will be the facility's responsibility to determine that, in fact, the order does support medical necessity prior to appending modifier 59.
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May 18, 2009
Question:
What sorts of things or activities would induce the anti-kickback statute
against labs?
Answer:
The following are examples of inducements offered by clinical laboratories
that may implicate the anti-kickback statute: free pick-up and disposal
of bio-hazardous waste products (such as sharps) unrelated to the collection
of specimens for the outside laboratory; provision of computers or fax machines,
unless such equipment is integral to, and exclusively used for, performance
of the outside laboratory's work; and provision of free laboratory testing
for health care providers, their families and their employees.
When one purpose of these arrangements is to induce the referral of program-reimbursed
laboratory testing, both the clinical laboratory and the health care provider
may be liable under the statute and may be subject to criminal prosecution
and exclusion from participation in the Medicare and Medicaid programs.
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May 11, 2009
Question:
How do you bill for the use of a blood warmer?
Answer:
The blood warmer is a reusable piece of equipment and is not separately billable.
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May 4, 2009
Question:
What is the proper way to bill when a hospital pays for blood as well as
processing and storage, which you covered in last week's answer?
Answer:
If you incur a charge for the blood or blood product in addition to the processing and storage, report those charges using revenue code series 038X (excluding 0380) with the following: line item date of service (LIDOS), number of units transfused, and appropriate blood product code and modifier BL.
In addition, report charges for processing and storage on a separate line using revenue code 0390, 0392, or 0399 along with the LIDOS, the number of units transfused, the appropriate blood product code, and modifier BL. Note, also, that the same LIDOS, the same number of units, the same HCPCS code, and HCPCS modifier BL must be reported on both lines.
This information and more about the April update to the hospital outpatient prospective payment system can be found in Transmittal 1702 at http://www.cms.hhs.gov/Transmittals/Downloads/R1702CP.pdf.
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April 27, 2009
Question:
What is the correct way to bill Medicare for storage of blood and blood
products?
Answer:
The Centers for Medicare & Medicaid Services provides guidelines on
this in Transmittal 1702 (http://www.cms.hhs.gov/Transmittals/Downloads/R1702CP.pdf.).
Specifically, when billing only for processing and storage, and not for
the blood itself, assign the appropriate code, the number of units transfused,
and the line item date of service (LIDOS) with one of the following revenue
codes:
- 0390-blood processing/storage;
- 0392-blood processing/storage; processing and storage; or
- 0399-blood processing/storage; other processing and storage.
Revenue code 0392 is a new revenue code, although the Centers for Medicare & Medicaid Services have not yet issued specific instructions about it.
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April 20, 2009
Question:
In your answer last week you addressed fair market value and provision
of supplies by labs to physicians. Does this fall under the category of
the antikickback statute?
Answer:
Yes. According to the Department of Health & Human Services Office of Inspector General (OIG), when the provision of free services results in a benefit to the provider, the anti-kickback statute is implicated. If offered or accepted in return for the referral of Medicare or state health care plan business, both the laboratory and the physician may be violating the anti-kickback statute. According to the OIG, there is no statutory exception or "safe harbor" to immunize any party to such a practice because the federal programs do not realize the benefit of these "free" services. Go to http://ecfr.gpoaccess.gov/cgi/t/text/text-idx?c=ecfr&tpl=%2Findex.tpl and search Title 42 and follow the steps to find Part 1001.952(h)(3)(iii).
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April 13, 2009
Question:
I believe that the answer you provided to the March 23 laboratory question
is incorrect or at least misleading. You stated that laboratories cannot
provide supplies, including vacutainer needles to physicians or other clients,
per the OIG. Please advise.
Answer:
You are correct that our answer to the March 23 question was incorrect.
We apologize for any confusion, and below is an amended and extended answer.
The provision of those items would be acceptable as long as the provision
of the supplies, services and equipment is not in any way shape or form
intended to induce Medicare, Medicaid or other federal healthcare program
patient referrals; and their use is specific to the provision of the services
provided by the reference laboratory; and the physician office does not
obtain any other type of financial benefit.
The Department of Health & Human Services Office of Inspector General
(OIG) addresses this topic in a December 19, 1994, Federal Register notice,
which includes the following statement:
"Whenever a laboratory offers or gives to a source of referrals anything
of value not paid for at fair market value, the inference may be made that
the thing of value is offered to induce the referral of business. The same
is true whenever a referral source solicits or receives anything of value
from the laboratory. By 'fair market value' we mean value for general commercial
purposes. However, 'fair market value' must reflect an arms length transaction
which has not been adjusted to include the additional value which one or
both of the parties has attributed to the referral of business between them."
For the OIG notice that contains the above and more information on the
topic, go to http://www.oig.hhs.gov/fraud/docs/alertsandbulletins/121994.html,
and scroll down to section F--Special Fraud Alert: Arrangements for the
Provision of Clinical Lab Services (Issued October 1994).
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April 6, 2009
Question:
A swab antigen was submitted for Influenza A or B, each (87400) of the
left nares and also the right nares. Is it appropriate to bill 87400 x 2?
Answer:
Chapter 10 of the National Correct Coding Initiative Policy Manual for Medicare Services includes numerous comments addressing the fact that Medicare does not pay for duplicate testing. Multiple procedures for the detection of the same infectious agent would not be billable.
We do not believe that the scenario you describe above supports billing duplicate testing of the swabs taken from left and right nares. However, CPT code 87400 is billable "each type" (87400 Influenza, A or B, each) reported. If the laboratory is reporting both Influenza A and Influenza B, CPT code 87400 would be billed X2.
For an overview of the NCCI edits and a link to the manual mentioned above, see http://www.cms.hhs.gov/NationalCorrectCodInitEd/.