Medicare reimbursement rules for clinical laboratory procedures are explained, including the proper use of procedure and diagnosis codes. Medicare coverage requirements, including medical necessity, are described, as well as the proper use of advance beneficiary notices and the Medicare appeals process. Fee schedules may be adjusted only by statutory changes approved by Congress. All patients should not receive the same number or type of sensitivity tests. Many payers interpret and apply coding rules in unique and sometimes arbitrary ways.
Medicare reimbursement for these panels is equal to the sum of the fee schedule amounts of the individual tests included. The carrier must acknowledge the request within 45 days and arrange for the date and time of the hearing. If a specific code exists for a given combination of tests, that code must be used. Billing Medicare Patients for Services That May be Denied Medicare patients may be billed for services that are clearly not covered. Specimen Collection Codes Specimen collection codes are used to identify phlebotomy and other services required to obtain body fluids or tissue for laboratory analysis. Medicare and most other payers allow a separate specimen collection charge for drawing or collecting specimens by venipuncture or catheterization whether the specimen is processed on site or referred to another laboratory for analysis.
The carrier must acknowledge the request within 45 days, and the response must come from someone not involved in the original payment determination. Abstract Medicare will continue to increase its efforts to cut spending through aggressive review of claims and the use of new fraud and abuse regulations. The Path and Lab section also includes a number of pathological tests. Tests in this section help determine the presence or response of certain important chemicals in the body as they are related to the immune system. If Medicare denies payment, I agree to be personally and fully responsible for payment. Non-routine venipunctures, such as those common to pediatrics and those performed in atypical vein sites, should be coded using cardiovascular codes, 36400-36410 or 36420-36425. There is an annual deductible and a 20% co-payment for all Part B services except outpatient clinical laboratory services.
Labs should also maintain all patient medical records supporting test as reasonable and necessary. Following the molecular pathology is the chemistry subsection. Part B is voluntary; however, most who are eligible sign up. Situation- specific waivers of liability must be obtained by a provider and signed by the patient if the patient is to be billed for tests or other services not covered by Medicare. Laboratory Modifiers 90 Reference lab; used to indicate a lab test was sent to a referral outside lab 91 Repeat clinical diagnostic laboratory test; used to report laboratory tests performed more than once on the same date to obtain subsequent, multiple test results. The precise basis for a national decision to noncover a procedure may be found in references cited in this policy. Molecular pathology procedures test genes, antigens, and a number of other biological functions to assess the possibility, or confirm the diagnosis of, a condition.
These codes replace the following general method codes, which have been deleted. These codes are used only for the laboratory component of the overall test. A laboratory panel is a package of tests that often are ordered together. The only way to assure full reimbursement for any given procedure is to regularly review claims payments. This modifier is used when it is necessary to obtain multiple results in the course of treatment, for example, concentrations of drugs or hormones during treatment or challenge tests.
Specimen collection performed by nursing home personnel for patients covered under Medicare Part A is paid for as part of the payment to the facility for its reasonable costs, not on the basis of the specimen collection fee. This new policy means that it is now impossible to improperly unbundle automated multichannel because any combination of individual tests and panels that contain automated, multichannel tests are to be accepted by Medicare Carriers. The mandatory assignment requirement for laboratory tests applies regardless of whether the physician is participating accepts assignment for all Medicare services or non-participating does not accept assignment for all Medicare services. The common procedure name is not repeated when used with more than one code. These procedures must be coded as precisely as possible. Until recently, such overpayments were treated as recovery actions by the carrier and subject only to the amount of the overpayment plus interest.
Medicare Payment Policy for Automated, Multichannel Tests Medicare has retained the automated, multichannel fee schedule for reimbursement purposes. Note that this panel cannot be coded as a Liver panel, 80058, because it does not include direct bilirubin. A separate fee is payable to cover transportation and expenses for trained personnel who travel to a nursing home or homebound patient to collect a sample. Unacceptable practices include a giving notice for all claims or services; b failing to list the specific reason or rationale for likely denial; and c failing to state the particular service which Medicare is likely to deny. Likewise, if the carrier underpays, the provider needs to refile the claim to receive proper payment. Coverage for prostate cancer screening using prostate-specific antigen and a digital rectal examination begins January 1, 2000. Such actions can also put a provider at risk of prosecution by the Medicare Office of Inspector General under the False Claims Act for submission of medically unnecessary claims.
The beneficiary is responsible for the remaining 20% once the annual deductible has been met. Modifiers are to be used sparingly. Medicare does not consider the general Health Panel 80050 and the Obstetric Panel 80055 to be covered services. Before Medicare pays for any test or diagnostic service, two basic criteria must be met: a the service must be covered by Medicare, and b the service must be medically necessary and indicated. The first portion of this subsection is made up of qualitative assays.
Local Medical Review Policy Local medical review policy dictates the coverage for clinical laboratory tests in regard to medical necessity issues. If appropriate diagnosis codes are not submitted showing the necessity for performing such tests, payment may be denied by Medicare. Thus, it would be wise to monitor all payments and promptly refund or refile to make sure that no liability is incurred for overpayments and that no payments are less than they should be. The code used determines what and if a laboratory will be paid for any given test or procedure. For example, routine physicals or screening tests such as total cholesterol or when there is no indication that the test is medically necessary. They are considered either experimental or investigational in nature They are routine physical examinations, for which Medicare does not pay under any circumstances because of statutory exclusions.