2015 Annual Notice to Providers

Transcription

1 8901 West Lincoln Avenue, West Allis, WI Pearl, Rosemont, IL Annual Notice to Providers April 2015 Dear Physician/Client: ACL Laboratories maintains an active compliance program that reflects our commitment to conduct business in compliance with all federal, state and local laws. As a participant in federally funded healthcare programs, ACL Laboratories is required by the Office of Inspector General (OIG) and the US Department of Justice (DOJ) to deliver annual provider education regarding laboratory compliance, billing and coding guidelines, and to inform our provider clients on the responsibilities we share. This annual notice specifies current Medicare/Medicaid program requirements and ACL policies. Please review the information contained in this notice and contact Kathy Lindgren, ACL Compliance Officer, at extension 7916 if you have any questions or concerns. ACL Laboratories must rely on you, our provider clients, for the following key compliance elements: Authorized Ordering Providers Laboratory testing must be ordered by a licensed physician or other individuals authorized by law. If your license has been revoked or suspended, you may no longer order or refer laboratory testing. Written and electronic orders must identify the ordering provider s National Provider Identifier (NPI). Effective January 5, 2014, providers must be enrolled in Medicare and Medicaid programs, and of a provider type that is eligible to order testing, for Medicare and Medicaid patients. Requirements for Diagnostic Information The Balanced Budget Act of 1997 specifies that the physician or practitioner ordering laboratory testing provide diagnostic information in the form of ICD-9 codes specific to the test(s) ordered at the time of the order. Please provide an ICD-9 code specific for a condition, disease, sign, symptom or complaint for each test ordered. When testing is ordered to determine or confirm a diagnosis, ICD-9 codes describing the signs, symptoms or chief complaints should be provided. It is the responsibility of the authorized ordering provider to document each ordered test and the corresponding diagnosis information in the patient s medical record. NOTE: As of the date of this document, the US Department of Health and Human Services (HHS) recognizes October 1, 2015 as the compliance date for ICD-10 implementation. This is a reminder that ACL Laboratories cannot submit claims for services without diagnosis codes directly obtained from the ordering provider. ACL expects our providers to accurately assign diagnosis information in conformance with ICD-10 standards. Requirements for Signatures Although the signature of the ordering provider is not required on laboratory requisitions, if signed, the requisition will serve as acceptable documentation of a physician order for the testing. In the absence of a signed requisition, documentation of your intent to order each laboratory test billed must be included in the patient s medical record and made available to ACL Billing, as needed. Documentation must accurately describe the individual tests ordered; it is not sufficient to state labs ordered. Laboratory orders may also be authorized or verified by electronic signature of the ordering provider Annual Notice to Providers 1

2 Medical Necessity Medicare will pay only for tests that meet Medicare coverage criteria and are reasonable and necessary to treat or diagnose an individual patient. Tests ordered to diagnose or treat patient signs, symptoms or complaints are subject to Medicare guidelines for medical necessity. Tests ordered in the absence of signs, symptoms or complaints are considered screening and are subject to Medicare Preventive Services benefits. Routine screening tests that have no preventive service coverage are the financial responsibility of the beneficiary. Medicare Preventive Services Medicare will pay for some laboratory tests when screening for disease. The CMS Quick Reference Information: Preventive Services guide lists the services covered along with applicable ICD-9 codes and frequency limitations. Advance Beneficiary Notices (ABN) Medicare can deny reimbursement for tests based upon absence of medical necessity, tests specified for investigational use only, tests ordered for routine screening (including tests ordered only as pre-operative screening), and when preventive services are ordered more frequently than screening benefits cover. Patients must be allowed to make an informed consumer decision as to whether to have testing performed when asked to assume financial responsibility of the cost of testing. A signed ABN is required by ACL whenever a test is requested that does not meet Medicare s Medical Necessity requirements, is being performed more frequently than screening benefits cover, or is considered experimental or research use only. It is the responsibility of the ordering provider to obtain a properly completed ABN when the Medicare beneficiary is serviced in his/her office. Molecular Pathology Procedures Many molecular pathology procedures are not considered covered services when ordered to assess disease risk or to screen for carrier status. Molecular tests may be eligible for coverage when results of the testing directly impacts treatment or management of a condition. Molecular tests may be subject to preauthorization and post payment medical record review. Please adhere to payer guidelines, as indicated. Qualitative Drug Screens Providers must order the drugs or drug classes for which screening is to be performed that reflect only those likely to be present based on the patient s medical history or current clinical presentation. Medical record documentation must indicate the medical necessity for performing a qualitative drug screen and identify all drugs/drug classes to be screened. Profiles Although profiles and test combinations offer convenience in ordering, they may result in the routine ordering of more tests than needed to diagnose and treat patients. Therefore, ACL limits the offering of profiles to those approved by the American Medical Association (AMA) and those that are approved by the laboratory s Pathology Medical Directors. Please know what tests are in each panel you order and do not order individual tests that might duplicate tests in the panel. Also, please order individual tests rather than a panel when all tests contained in the panel are not required for diagnosis or treatment purposes. The ACL Directory of Services identifies the individual tests included in a panel under Components Annual Notice to Providers

3 Reflex Testing Reflex testing occurs when initial test results are positive or outside normal parameters and general medical practice indicates a second related test is medically appropriate to confirm or validate the initial test results. Unless confirmatory reflex testing is required by law, tests may be ordered with or without reflex criteria. When ordering tests that include reflex criteria, it is also necessary to document the reflex order in the patient s medical record, e.g., CBC w/diff, Lipid Panel w/ldl reflex, UA w/microscopic exam. The ACL Directory of Services lists reflex and/or confirmation criteria under Test Performance. When indicated, ACL will bill for reflex tests along with the initial test. Recurring Orders Recurring orders are permissible when all of the following criteria are met: The order identifies an individual patient The order specifies each ordered test The order indicates the frequency and duration of testing (e.g., Hemoglobin A1c, every 3 mos for 1 yr) The diagnosis provided supports the frequency of testing (e.g., Hemoglobin A1c, ICD-9 code ) Recurring orders are valid for a maximum of 365 days from original order date and must be renewed annually. Clinical Consultant ACL Laboratories is affiliated with over 90 board-certified Pathologists in a variety of specialties that are available to provide technical or consultative services regarding appropriate test use and ordering. Please call ACL Client Services department at to request laboratory testing assistance. Addendum to the 2015 Annual Notice to Providers Table of Contents for References ACL Directory of Services Website... 4 Medicare Fee Schedule for Clinical Laboratory Tests... 4 OIG Notice... 4 Medicare Enrollment Information... 4 Provision of Diagnosis Codes... 4 Signature Requirements... 4 National Coverage Determination Policies... 5 Local Coverage Determination Policies... 5 Lab Tests with Preventive Service Coverage... 6 ABN Requirements... 7 AMA Recognized Panels Annual Notice to Providers 3

4 Additional Test Information and Website References An electronic version of ACL Laboratories Directory of Services (DOS) can be accessed on the following web site: ACL s DOS includes our clinical test menu, test order codes, and CPT code(s) used to bill Medicare. Correct CPT coding can vary by carrier; therefore, the codes referenced are intended as general guidelines and should not be used without confirming their appropriateness with applicable payers. Medicare reimbursement for the laboratory CPT codes may be found on the following web site: Wisconsin Medicaid reimbursement may be found on the following web site: Illinois Medicaid reimbursement may be located at the following web site: OIG Notice: Only tests that meet Medicare coverage policies may be submitted for reimbursement. Individuals who knowingly cause a false claim to be submitted to Medicare may be subject to sanctions or remedies available under civil, criminal and administrative law. To avoid false claim submission, be sure to: 1. Order only those tests necessary for diagnosis or treatment. Note: Each component of a panel must be necessary for the panel to qualify for Medicare reimbursement. 2. Provide a diagnosis, sign or symptom for each test ordered. 3. Document this information in the patient s medical record. 4. Obtain an ABN from the Medicare patient when tests do not meet medical necessity criteria. Eligible Provider Enrollment (PECOS): MLN Matters SE 1305 Physicians and others who are eligible to order and refer items or services need to establish their Medicare enrollment record with a valid National Provider Identifier (NPI) and must be of a specialty that is eligible to order and refer. SE1305.pdf Provision of Diagnostic Information: CMS Transmittal B ICD-10 Resources: Signature Requirements: MLN Complying with Medicare Signature Requirements Signature_Requirements_Fact_Sheet_ICN pdf Annual Notice to Providers

5 Medical Necessity Policies Laboratory Tests: The Center for Medicare and Medicaid Services (CMS) has published 23 National Coverage Determinations (NCD) that specify the medical conditions that will be covered for commonly ordered lab tests. The Laboratory NCDs may be found on the web at: aspx?bc=baaaaaaaaaaa& CMS has authorized National Government Services, the Illinois, Wisconsin and Minnesota Medicare Part B carrier, to develop Local Coverage Determination Policies (LCDs) and Supplemental Instruction Articles (SIAs). These guidelines may supplement or be in addition to NCDs, give direction for medical necessity on selected tests and can be found at: National Coverage Policies Alpha-fetoprotein Blood Counts (CBC) CA 125, CA15-3/CA27.29, CA 19-9, CEA Collagen Crosslinks Digoxin Fecal Occult Blood GGTP Glucose Hemoglobin A1C Hepatitis Panel, Acute hcg HIV Testing, Diagnosis & Prognosis Iron Studies (Iron, Ferritin, Transferrin) Lipid Testing Prostate Specific Antigen (PSA) PTT PT/INR Thyroid Testing (TSH, T4, T3) Urine Culture Local Coverage Policies B-type Natriuretic Peptide (BNP) Circulating Tumor Cell (CTC) Drug Screens, Qualitative Galectin-3 Heavy Metal Testing (Lead, Zinc, Cobalt, etc) Molecular Pathology MRSA (Methicillin Resistant detection by DNA or RNA) Pre-operative Testing (Non-covered Services) OVA1 (Combined Ovarian Cancer Biomarker) RAST Allergen Tests (IgE, IgG) Vitamin D Assay 2015 Annual Notice to Providers 5

6 Quick Reference Information: Preventive Services guide for a list of tests, applicable ICD-9 codes and frequency limits at: QuickReferenceChart_1.pdf Laboratory Service HCPCs/CPT Codes Applicable ICD-9 Codes Frequency Cardiovascular Screening Lipid Panel Cholesterol HDL Cholesterol Triglycerides Covered when one of the following are reported: V81.0, V81.1, V81.2 Every 5 years Diabetes Screening Glucose Glucose; post-glucose Glucose; tolerance V per year, or 2 per year, if diagnosed with pre-diabetes PAP Screens G0123, G0124, G0143, G0147 Covered when one of the following are reported: V72.31, V76.2, V76.47, V76.49 Low Risk V15.89 High Risk Every 24 months, if Low Risk Annually, if High Risk Colorectal Cancer Screening G0328 FOBT, Immunoassay FOBT, Guaiac Annually Prostate Cancer Screening G0103 PSA V76.44 Annually Hepatitis C Screening (HCV) G0472 HCV Adults born between 1945 & 1965, not at high risk / Adults meeting high risk definition Once per lifetime 1 annual screening with continued risk factors HIV Screening G0432 EIA technique G0433 ELISA technique V73.89 Primary V22.0, V22.1, V69.8 or V23.9 Secondary, as appropriate Annually Sexually Transmitted Infections (STIs) Screening 86631, 86632, 87110, Chlamydia Gonorrhea 86592, 86593, Syphilis 87340, Hepatitis B Surface Antigen Chlamydia, gonorrhea & syphilis in women at increased risk who are not pregnant: V74.5 & V69.8 Syphilis in men at increased risk: V74.5 & V69.8 Chlamydia & gonorrhea in pregnant women at increased risk: V74.5 & V69.8 plus either V22.0, V22.1 or V23.9 Syphilis in pregnant women: V74.5 and either V22.0, V22.1 or V23.9 Hepatitis B in pregnant women: V73.89 and either V22.0, V22.1 or V23.9 Hepatitis B in pregnant women at increased risk: V73.89 & V69.8 and either V22.0, V22.1 or V annual screening for chlamydia, gonorrhea and syphilis in women at increased risk who are not pregnant 1 annual screening for syphilis in men at increased risk Up to 2 screenings per pregnancy for chlamydia and gonorrhea if at continued increased risk 1 screening per pregnancy for syphilis; up to 2 additional screenings if at continued increased risk 1 screening per pregnancy for hepatitis B; 1 additional screening if at continued increased risk Annual Notice to Providers

7 Advance Beneficiary Notices (ABN) Transfer of financial liability to the patient ABN Form CMS-R-131 is issued by providers (including independent laboratories), physicians, and practitioners to Medicare fee-for-service beneficiaries in situations where Medicare payment is expected to be denied. Patients must have sufficient time to make an informed decision on whether or not to receive the test in question and accept potential financial liability. CMS Form R-131 and instructions for use and completion can be found at: AMA Recognized Organ/Disease Panels Panel Order Code Panel Name & Components Panel CPT Code WI Medicare IL Medicare WI Medicaid IL Medicaid BPNL Basic Metabolic Panel Calcium Glucose CO 2 Potassium Chloride Sodium Creatinine BUN $11.51 $11.51 $11.54 $8.06 CPNL Comprehensive Metabolic Panel ALT Chloride Albumin Creatinine Alk Phos Glucose AST Potassium Calcium Protein, Total CO 2 Sodium Bilirubin, Total BUN $14.37 $14.37 $14.41 $10.08 ELEPNL Electrolyte Panel Sodium Chloride $9.55 $9.55 $9.57 $6.67 Potassium CO 2 HACUTE Hepatitis Panel, Acute with Reflexes A Ab, IgM (AIGM) Hepatitis B Surface Ag (HBAG) Hepatitis B Core IgM (HEPCM) Hepatitis C Ab (HCV) $64.83 $64.83 $64.99 $37.44 LIVPNL Hepatic Function Panel (Liver Panel) ALT Bilirubin, Total Albumin Bilirubin, Direct Alk Phos Protein, Total AST $11.11 $11.11 $11.14 $7.76 LIPDPL Lipid Panel (without reflex) Cholesterol HDL Triglyceride LDL, calc $18.22 $18.22 $18.27 $ Annual Notice to Providers 7

8 Panel Order Code Panel Name & Components Panel CPT Code WI Medicare IL Medicare WI Medicaid IL Medicaid LIPPNL not to be ordered for screening Lipid Panel (with reflex Direct LDL) Cholesterol HDL Triglyceride LDL, calc. When Triglyceride >400, a LDL, Direct will be performed and charged $18.22 $12.99 $18.22 $12.99 $18.27 $13.02 $6.05 $9.09 RENPNL Renal Panel Albumin Calcium CO 2 Chloride Creatinine Glucose Phosphorus Potassium Sodium BUN $11.82 $11.82 $11.85 $ Annual Notice to Providers 4/15 MC 0612