DEPARTMENT: Regulatory Compliance Support

Transcription

1 PAGE: 1 of 5 REPLACES POLICY DATED: 1/16/98, 3/1/99, SCOPE: All Company-affiliated hospitals performing and/or billing laboratory services. Specifically, the following departments: Business Office Admitting/Registration Administration Revenue Integrity Health Information Management Reimbursement Nursing Laboratory Case Management Shared Services Centers PURPOSE: To establish guidelines for billing Organ and Disease panels in accordance with Medicare, Medicaid, and other federally-funded payer requirements. POLICY: Organ and Disease panels and component tests billed to a federally-funded program must be based on a written order and be medically necessary. Only Centers for Medicare and Medicaid Services (CMS)-approved Organ and Disease panels will be billed at the panel level to Medicare, Medicaid and other federally-funded payers, unless the payer has provided written documentation regarding the acceptance of other American Medical Association defined Organ and Disease panels. Chemistry components will be bundled to the panel level when all of the tests in the panel are ordered and performed. Repeated laboratory tests, including repeated components of panels, may be billed when the tests are medically necessary, which is indicated by reporting modifier 91. Modifier 91 may only be reported when in the course of treating a patient, it is necessary to repeat the same laboratory test on the same day to obtain subsequent test results. This modifier may not be reported when tests are rerun to confirm initial results; due to testing problems with specimens or equipment; or for any other reason when a normal, one-time, reportable result is all that is required. This modifier may not be used when other code(s) describe a series of test results (e.g., glucose tolerance tests, evocative/suppression testing). If a payer does not recognize or accept modifier 91 and the payer has not provided you with their specific billing guidance for repeated laboratory tests, these tests may not be billed. If a CPT code is a component of a CMS-approved Organ and Disease panel, a subsequent test performed on a different specimen type may be billed when medically necessary, which is indicated by reporting modifier 59. If a payer does not recognize or accept modifier 59 and the payer has not provided you with their specific billing guidance for repeated laboratory tests, these tests may not be billed. CMS has established Medically Unlikely Edits (MUE) and National Correct Coding Initiative

2 PAGE: 2 of 5 REPLACES POLICY DATED: 1/16/98, 3/1/99, (NCCI) edits. MUEs may trigger when units of service on a given claim line item exceed the established limit for that HCPCS code. NCCI edits may trigger when there are restrictions on code combinations reported on a single date of service. MUEs and/or NCCI edits may supersede information within this policy. PROCEDURE: The following steps must be performed when billing Organ and Disease panels to Medicare, Medicaid, and other federally-funded programs. IMPLEMENTATION 1. Assign CPT/HCPCS codes and revenue codes for each panel and panel component test in accordance with the Company Standard Laboratory Chargemaster. Set-up the Laboratory and Order Entry dictionaries or masterfiles to enable the ordering and billing of panels Basic Metabolic Panel (Calcium, Ionized) National Limit Amount $12.12 Calcium, ionized (82330) Urea Nitrogen (BUN) (84520) Basic Metabolic Panel (Calcium, Total) National Limit Amount $12.12 Calcium, total (82310) Electrolyte Panel National Limit Amount $ 10.05

3 PAGE: 3 of 5 REPLACES POLICY DATED: 1/16/98, 3/1/99, Comprehensive Metabolic Panel National Limit Amount $15.14 Bilirubin, total (82247) Calcium, total (82310) Phosphatase, alkaline (84075) Protein, total (84155) Transferase, alanine amino (ALT),(SGPT) (84460) Transferase, aspartate amino (AST) (SGOT) (84450) Lipid Panel National Limit Amount - None State Range: Low: $14.04 High: $19.19 Cholesterol, serum, total (82465) Lipoprotein, direct measurement, high density cholesterol (HDL cholesterol) (83718) Triglycerides (84478) Renal Function Panel National Limit Amount $12.43 Calcium; total (82310) Phosphorus inorganic (phosphate) (84100)

4 PAGE: 4 of 5 REPLACES POLICY DATED: 1/16/98, 3/1/99, Acute Hepatitis Panel National Limit Amount None Revenue Code 300 State Range: Low: $58.95 High: $68.21 Hepatitis A antibody (HAAb), IgM antibody (86709) Hepatitis B core antibody (HBcAb), IgM antibody (86705) Hepatitis B surface antigen (HBsAg) (87340) Hepatitis C antibody (86803) Hepatic Function Panel National Limit Amount $11.70 Bilirubin; total (82247) Bilirubin; direct (82248) Phosphatase, alkaline (84075) Protein, total (84155) Transferase, aspartate amino (AST) (SGOT) (84450) Transferase, alanine amino (ALT) (SGPT) (84460) 2. Business Office or Service Center personnel must verify that edits are present in the electronic billing system which: a. Bundle individual component tests to the most comprehensive panel level as defined in this procedure. b. Compare individual component tests within each panel to any component tests not billed as part of a panel and identify repeated tests. c. Compare individual component tests of multiple panels and identify duplicate components. 3. Laboratory and Business Office/Service Center personnel must educate all staff associates responsible for ordering, charging, or billing laboratory services regarding the requirements of this policy. 4. Monitoring activities must be completed in accordance with the Billing Monitoring Policy, REGS.GEN.001. DAILY 1. It is recommended but not required that laboratory personnel review daily charge reports (e.g., Ancillary Charge Report, NPR charge reports, etc.) to verify compliance with this policy as follows:

5 PAGE: 5 of 5 REPLACES POLICY DATED: 1/16/98, 3/1/99, a. Bundle individual component tests to the most comprehensive panel level as defined in this procedure. b. Compare individual component tests within each panel to any component tests not billed as part of a panel and identify repeated tests. c. Compare individual component tests of multiple panels and edit for duplicate components. 2. Service Center or Business Office personnel must review electronic billing edit/error reports daily and perform the following: a. Bundle chemistry components to the appropriate comprehensive panel. b. Identify the presence of repeated panels and component tests and determine if documentation is present to support medical necessity. i. Append the appropriate modifier (59 or 91) to repeated tests or panels which are medically necessary. ii. Eliminate repeated tests or panels which are not medically necessary. Modify number of units and related charges in the electronic billing vendor system to reflect the appropriate charge for the panel being billed. The Facility Ethics and Compliance Committee is responsible for implementation of this policy within the facility. REFERENCES: 1. Medicare Claims Processing Manual, Chapter 16, Section AMA CPT Assistant, Summer 1993 Pages: AMA CPT Assistant, January 1998 Pages: American Medical Association Physicians Current Procedural Terminology CPT 5. Current Year Clinical Lab Fee Schedule 6. CMS website - National Correct Coding Initiative edits