(Medicare Claims Processing Manual)

An independent laboratory that furnishes the TC of physician pathology services to inpatients or outpatients of a hospital that is not a covered hospital may not bill the A/B MAC (B) for TC of physician pathology services furnished to patients of that hospital.   An independent laboratory or other entity that has an arrangement with a covered hospital should forward a copy of this agreement or other documentation to its A/B MAC (B) to confirm that an arrangement was in effect between the hospital and the independent laboratory as of July 22, 1999.  This documentation should be furnished for each covered hospital the independent laboratory or other entity services.  If the laboratory or other entity did not have an arrangement with the covered hospital as of July 22, 1999, but has subsequently entered into an arrangement, then it should obtain a copy of the arrangement between the predecessor laboratory or other entity and the covered hospital and furnish this to the A/B MAC (B).  The A/B MAC (B) maintains a hard copy of this documentation for postpayment reviews.   Please Note:  Effective on or after July 1, 2012, only the hospital may bill for the TC of a physician pathology service provided to an inpatient or outpatient.  Neither example 1 nor example 2 above will apply for claims with dates of service on or after July 1, 2012.  80.3 - National Minimum Payment Amounts for Cervical or Vaginal Smear Clinical Laboratory Tests  (Rev. 1, 10- 01-03) PM AB -99-84, AB -99-99  For cervical or vaginal smear clinical laboratory tests, payment is the lesser of the local fee or the national limitation amount, but not less than the national minimum payment amount (NMPA).  However, in no case may payment for these tests exceed actual charges.  The Part B deductible and coinsurance do not apply.  For tests performed on or after January 1, 2000, a NMPA of $14.60 is established and applies for cervical or vaginal smear clinical laboratory tests in accordance with 224 of the Balanced Budget Refinement Act (Public Law 106- 113).  The affected CPT labor atory test codes for the NMPA are 88142, 88143, 88144, 88145, 88147, 88148, 88150, 88152, 88153, 88154, 88164, 88165, 88166, 88167, G0123, G0143, G 0144, G0145, G0147, G0148, and P3000.  The NMPA will be reviewed and updated in conjunction with the clinical laboratory fee schedule, as required.  Instructions for such updates will be sent to A/B MACs (A) and (B) through periodic temporary instructions.   80.4 - Oximetry  (Rev. 1, 10- 01-03) B3-5114.1  Certain blood gas levels are determined either by invasive means through use of a blood specimen for a clinical laboratory test or by noninvasive means through ear or pulse oximetry, which is not considered a clinical laboratory test.  CPT code 82792 is us ed for invasive oximetry.  HCPCS code M0592 is used for ear and pulse oximetry.  Code M0592 is not subject to fee schedules.   90 - Automated Profile Tests and Organ/Disease Oriented Panels  (Rev. 1, 10- 01-03)  The term profile or panel means a grouping of laboratory tests, which is usually performed automatically on a single piece of testing equipment.  90.1 - Laboratory Tests Utilizing Automated Equipment  (Rev. 4299; Issued: 05- 03-19; Effective: 01 -01-19; Implementation: 10 -07-19) B3-5114, HO -437, A3- 3628  Clinical laboratory tests are covered under Medicare if they are reasonable and necessary for the diagnosis or treatment of an illness or injury.  Because of the numerous technological advances and innovations in the clinical laboratory field and the incre ased availability of automated testing equipment, no distinction is generally made in determining payment for individual tests because of either (1) the sites where the service is performed, or (2) the method of the testing process used, whether manual or automated.  Whether the test is actually performed manually or with automated equipment, the services are considered similar and the payment is the same.   90.1.1 - Automated Test Listing  (Rev. 4299, Issued: 05- 03-19, Effective: 01 -01-19, Implementation: 10 -07-19) B3-5114, HO -437, A3- 3628, PMs AB -97-5, AB -97-7, AB -97-17  Profiles are specific groupings of blood chemistries that enable physicians to more accurately diagnose their patients medical problems.  While the component tests in automated profiles may vary somewhat from one laboratory to another, or from one physicians office or clinic to another, in order to develop appropriate payment amounts, A/B MACs (A) and (B) group together those profile tests that can be performed at the same time on the same equipment.  The A/B MAC (A) or (B) must group together the individual tests in the profile when billed separately and consider the price of the related automated profile test.  Payment cannot exceed the lower of the profile price or the totals of the prices of all the individual tests.  (This rule is applicable also if the tests are done manually.)  The profile HCPCS code and each individual test is priced at the lower of the billed charge or the fee amount; and payment is made at the lower of the profile/panel price or the total of the prices for all covered components.   Payment is made only for those tests in an automated profile that meet Medicare coverage rules.  Where only some of the tests in a profile of tests are covered, payment cannot exceed the amount that would have been paid if only the covered tests had been ordered.  For example, the use of the 12- channel serum chemistry test to determine the blood sugar level in a proven case of diabetes is unreasonable because the results of a blood sugar test performed separately provide the essential information.  Normally, the payment allowance for a blood sugar test is lower than the payment allowance for the automated profile of tests.  In no event, however, may payment for the covered tests exceed the payment allowance for the profile.   However, the A/B MAC (B)  prices and pays the 1 -22 automated multi-channel chemistry tests tested in 90.2 at the lowest possible amount in accordance with 90.3.  As of January 1, 2018, the profiles referenced in the above section are no longer recognized by Medicare.  The Protecting Access to Medicare Act of 2014 requires Medicare to pay a weighted median collected from private payor rates for each HCPCS code on the CLFS.  Therefore the automated profiles described above are no longer used to pay for the automated profiles of tests.    90.2 - Organ or Disease Oriented Panels  (Rev. 4299, Issued: 05- 03-19, Effective: 01-01-19, Implementation: 10-07-19)  Prior to January 1, 2018, organ or disease panels must be paid at the lower of the billed charge, the fee amount for the panel, or the sum of the fee amounts for all components.    Payment for the total panel may not exceed the sum total of the fee amounts for individual covered tests.  All Medicare coverage rules apply.  The Medicare shared systems must calculate the correct payment amount.  The CMS furnishes fee prices for each code but the A/B MAC (A) or (B) system must compare individual codes billed with codes and prices for related individual tests.  (With each HCPCS update, HCPCS codes are reviewed and the system is updated).  Once the codes are identified, A/B MACs (A) and (B) publish panel codes to providers.  The only acceptable Medicare definition for the component tests included in the CPT codes for organ or disease oriented panels is the American Medical Association (AMA) definition of component tests.  The CMS will not pay for the panel code unless all of the tests in the definition are performed.  If the laboratory has a custom panel that includes other tests, in addition to those in the defined CPT or HCPCS panels, the a dditional tests,  are billed separately in addition to the CPT or HCPCS panel code.  NOTE:   If a laboratory chooses, it can bill each of the component tests of these panels individually, but payment will be based upon the above rules.  Effective for claims with dates of service on or after January 1, 2019, laboratories shall bill the HCPCS panel test code and not unbundle the individual components if all components of the HCPCS panel are performed. Claims will be returned as unprocessable/rejected if the HCPCS panel test code is not billed. Providers and suppliers are required to submit all AMCC laboratory test HCPCS for the same beneficiary, performed on the same date of service on the same claim. This billing policy applies when:  a). Submitting a complete organ disease panel; or  b). Submitting individual component tests of an organ disease panel when all components of the panel were not performed.  TABLE OF CHEMISTRY PANELS    Hepatic Function  Panel  80076  Basic  Metabolic  Panel  (Calcium, ionized)  80047  Basic  Metabolic  Panel  (Calcium, total)  80048  Comprehensive  Metabolic  Panel  80053  Renal  Function  Panel  80069  Lipid1 Panel  80061  Electrolyte Panel  80051  Chemistry  CPT         Albumin  82040  X   X X   Alkaline phosphatase  84075  X   X    ALT (SGPT)  84460  X   X    AST (SGOT)  84450  X   X    Bilirubin, total  82247  X   X    Bilirubin, direct  82248  X       Calcium  82310    X X X   Calcium ionized  82330   X      Chloride  82435   X X X X  X Cholesterol  82465       X  CK, CPK  82550         CO2 (bicarbonate)  82374   X X X X  X Creatinine  82565   X X X X   GGT  82977         Glucose  82947   X X X X   LDH  83615         Phosphorus  84100      X    1  CPT code 83718 is billed with Organ/Disease Panel 80061 but is not included in the AMCC bundling.    Hepatic Function  Panel  80076  Basic  Metabolic  Panel  (Calcium, ionized)  80047  Basic  Metabolic  Panel  (Calcium, total)  80048  Comprehensive  Metabolic  Panel  80053  Renal  Function  Panel  80069  Lipid1 Panel  80061  Electrolyte Panel  80051  Chemistry  CPT         Potassium  84132   X X X X  X Protein  84155  X   X    Sodium  84295   X X X X  X Triglycerides  84478       X  Urea nitrogen (BUN)  84520   X X X X   Uric Acid  84550          90.3 - Claims Processing Requirements for Panel and Profile Tests  (Rev. 4299, Issued: 05- 03-19, Effective: 01-01-19, Implementation: 10-07-19)  All test codes should be processed and stored in history as they are submitted.  That is, if tests are submitted as individual CPT codes together and paid as a panel (see 90), the claim history data will reflect the individual codes and the panel used in pricing.  All tests must maintain their identity as billed.   Prior to January 1, 1998, automated panel codes were adjudicated only on a line-by- line basis with application of the correct coding initiative (CCI) edits for duplicate detection.   As of January 1, 1998, when individual automated test codes are received, A/B MACs (A) and (B) did not combine them into panels for processing.  The only instance in which they should be panel codes is when they were coded as such on the claim.  Beginning January 1, 2018, Medicare does not recognize automated test panels, unless a panel has its own CPT code, as described in section 90.2.    A/B MACs (A) and (B)   1. Deny Duplicates.  Deny duplicate services detected within the same processing cycle or stored in an automated history file.  Consider claims that match on the following items as duplicates   a. The service was performed by the same provider,  b. For the same beneficiary, and  c. For the same date of service.   2. Medical Necessity .  Determine medical necessity.  This process permits the identification of CPT codes subject to local medical review policies.