(Medicare Claims Processing Manual)

 The test is not related to the treatment of ESRD, in which case the supplier would append modifier AY.   A/B MACs (B) shall make payment for organ disease panels according to the Clinical Laboratory Fee Schedule and shall apply the normal ESRD PPS editing rules for independent laboratory claims.  The aforementioned organ disease panel codes were added to the list of bundled ESRD PPS laboratory tests in January 2012.  Effective for dates of service on and after April 1, 2015, A/B MACs (A) shall allow organ disease panel codes (i.e., HCPCS codes 80047, 80048, 80051, 80053, 80061, 80069, and 80076) to be billed by ESRD facilities for AMCC panel tests furnished to ESRD eli gible beneficiaries if:    These codes best describe the laboratory services provided to the beneficiary, which are paid under the ESRD PPS, or    The test is not related to the treatment of ESRD, in which case the ESRD facility would append modifier AY and the service may be paid separately from the ESRD PPS.   Instructions for Services Provided Prior to January 1, 2011  For claims with dates of service prior to January 1, 2011, Medicare will apply the following rules to Automated Multi- Channel Chemistry (AMCC) tests for ESRD beneficiaries:   Payment is at the lowest rate for tests performed by the same provider, for the same beneficiary, for the same date of service.    The facility/laboratory must identify, for a particular date of service, the AMCC tests ordered that are included in the composite rate and those that are not included.  See Publication 100-02, Chapter 11, Section 30.2.2 for the chart detailing the composi te rate tests for Hemodialysis, Intermittent Peritoneal Dialysis (IPD), Continuous Cycling Peritoneal Dialysis (CCPD), and Hemofiltration as well as a second chart detailing the composite rate tests for Continuous Ambulatory Peritoneal Dialysis (CAPD).   If 50 percent or more of the covered tests are included under the composite rate payment, then all submitted tests are included within the composite payment.  In this case, no separate payment in addition to the composite rate is made for any of the separa tely billable tests.    If less than 50 percent of the covered tests are composite rate tests, all AMCC tests submitted for that Date of Service (DOS) for that beneficiary are separately payable.    A noncomposite rate test is defined as any test separately payable outside of the composite rate or beyond the normal frequency covered under the composite rate that is reasonable and necessary.   For A/B MAC (B) processed claims, all chemistries ordered for beneficiaries with chronic dialysis for ESRD must be billed individually and must be rejected when billed as a panel.  (See 100.6UH for details regarding pricing modifiers.)  Implementation of this Policy:  ESRD facilities when ordering an ESRD -related AMCC must specify for each test within the AMCC whether the test:  a. Is part of the composite rate and not separately payable;   b. Is a composite rate test but is, on the date of the order, beyond the frequency covered under the composite rate and thus separately payable; or   c. Is not part of the ESRD composite rate and thus separately payable.   Laboratories must:   a. Identify which tests, if any, are not included within the ESRD facility composite rate payment   b. Identify which tests ordered for chronic dialysis for ESRD as follows:   1) Modifier CD:  AMCC Test has been ordered by an ESRD facility or MCP physician that is part of the composite rate and is not separately billable.   2) Modifier CE:  AMCC Test has been ordered by an ESRD facility or MCP physician that is a composite rate test but is beyond the normal frequency covered under the rate and is separately reimbursable based on medical necessity.   3) Modifier CF:  AMCC Test has been ordered by an ESRD facility or MCP physician that is not part of the composite rate and is separately billable.   c. Bill all tests ordered for a chronic dialysis ESRD beneficiary individually and not as a panel.   The shared system must calculate the number of AMCC tests provided for any given date of service.  Sum all AMCC tests with a CD modifier and divide the sum of all tests with a CD, CE, and CF modifier for the same beneficiary and provider for any given date  of service.   If the result of the calculation for a date of service is 50 percent or greater, do not pay for the tests.   If the result of the calculation for a date of service is less than 50 percent, pay for all of the tests.  For A/B MAC (A) processed claims, all tests for a date of service must be billed on the monthly ESRD bill.  Providers that submit claims to an A/B MAC (A) must send in an adjustment if they identify additional tests that have not been billed.   A/B MAC (B) shared systems shall adjust the previous claim when the incoming claim for a date of service is compared to a claim on history and the action is adjust payment.  A/B MAC (B) shared systems shall spread the payment amount over each line item on both claims (the claim on history and the incoming claim).  The organ and disease oriented panels (80048, 80051, 80053, and 80076) are subject to the 50 percent rule.  However, clinical diagnostic laboratories shall not bill these services as panels, they must be billed individually.  Laboratory tests that are not covered under the composite rate and that are furnished to CAPD end stage renal disease (ESRD) patients dialyzing at home are billed in the same way as any other test furnished home patients.   A/B MAC (A) Business Requirements for ESRD Reimbursement of AMCC Tests:  Requirement Number  Requirement  Responsibility  1.1 The A/B MAC (A) shared system must RTP a claim for AMCC tests when a claim for that date of service has already been submitted.  Shared system  1.2 Based upon the presence of the CD, CE and CF payment modifiers, identify the AMCC tests ordered that are included and not included in the composite rate payment.  Shared System  1.3 Based upon the determination of requirement 1.2, if 50 percent or more of the covered tests are included under the composite rate, no separate payment is made.  Shared System  1.4 Based upon the determination of requirement 1.2, if less than 50 percent are covered tests included under the composite rate, all AMCC tests for that date of service are payable.  Shared System  1.5 Effective for claims with dates of service on or after January 1, 2006, include any line items with a modifier 91 used in conjunction with the CD, CE, or CF modifier in the calculation of the 50/50 rule.  Shared System  1.6 A/B MACs (A) must return any claims for additional tests for any date of service within the billing period when the provider has already submitted a claim.  Instruct the provider to adjust the first claim.  A/B MAC (A) or Shared System  1.7 After the calculation of the 50/50 rule, services used to determine the payment amount may never exceed 22.  Effective for claims with dates of service on or after January 1, 2006, accept all valid line items submitted for the date of service and pay a maximum of the ATP 22 rate.  Shared System    A/B MAC (B) Business Requirements for ESRD Reimbursement of AMCC Tests: Requirement Number  Requirement  Responsibility  1 The shared systems shall calculate payment at the lowest rate for these automated tests even if reported on separate claims for services performed by the same provider, for the same beneficiary, for the same date of service.  Shared Systems  2 Shared  Systems shall identify the AMCC tests ordered that are included and are not included in the composite rate payment based upon the presence of the CD, CE and CF modifiers.  Shared  Systems  3  Based upon the determination of requirement 2 if 50 percent or more of the covered services are included under the composite rate payment, Shared  Systems shall indicate that no separate payment is provided for the services submitted for that date of service.  Shared  Systems  4 Based upon the determination of requirement 2 if less than 50 percent are covered services included under the composite rate, Shared  Systems shall indicate that all AMCC tests for that date of service are payable under the 50/50 rule. Shared  Systems  Requirement Number  Requirement  Responsibility  5 Effective for claims with dates of service on or after January 1, 2006, include any line items with a modifier 91 used in conjunction with the CD, CE, or CF modifier in the calculation of the 50/50 rule.  Shared  Systems  6 Shared  Systems shall adjust the previous claim when the incoming claim is compared to the claim on history and the action is to deny the previous claim.  Spread the payment amount over each line item on both claims (the adjusted claim and the incoming claim).  Shared  Systems  7 Shared  Systems shall spread the adjustment across the incoming claim unless the adjusted amount would exceed the submitted amount of the services on the claim.  Shared  System  8 After the calculation of the 50/50 rule, services used to determine the payment amount may never exceed 22.  Accept all valid line items for the date of service and pay a maximum of the ATP 22 rate.  Shared  Systems   Examples of the Application of the 50/50 Rule   The following examples are to illustrate how claims should be paid.  The percentages in the action section represent the number of composite rate tests over the total tests.  If this percentage is 50 percent or greater, no payment should be made for the claim.   Example 1:  Provider Name:  Jones Hospital   DOS 2/1/02, Claim/Services:  CPT Code - Modifier  82040  Mod CD  82310  Mod CD  82374  Mod CD  82435  Mod CD  82947  Mod CF  84295  Mod CF  82040  Mod CD (Returned as duplicate)  84075  Mod CE  82310  Mod CE  84155  Mod CE  ACTION:  9 services total, 2 non- composite rate tests, 3 composite rate tests beyond the frequency, 4 composite rate tests; 4/9 = 44.4%<50% pay at ATP 09  Example 2:  Provider Name:  Bon Secours Renal Facility  DOS 2/15/02, Claim/Services:  CPT Code  Modifier  82040  Mod CE and Mod 91  84450  Mod CE  82310  Mod CE  82247  Mod CF  82465  No modifier present  CPT Code  Modifier  82565  Mod CE  84550  Mod CF  82040  Mod CD  84075  Mod CE  82435  Mod CE  82550  Mod CF  82947  Mod CF  82977  Mod CF  ACTION:  12 services total, 5 non- composite rate tests, 6 composite rate tests beyond the frequency, 1 composite rate test; 1/12 = 8.3%<50% pay at ATP 12  Example 3:  Provider Name:  Sinai Hospital Renal Facility  DOS 4/02/02, Claim/Services:  CPT Code  Modifier  82565  Mod CD  83615  Mod CD  82247  Mod CF  82248  Mod CF  82040  Mod CD  84450  Mod CD  82565  Mod CE  84550  Mod CF  82248  Mod CF (Duplicate  ACTION:  8 services total, 3 non- composite rate tests, 4 composite rate tests, 1 composite rate test beyond the frequency; 4/8 = 50%, therefore no payment is made.  Example 4:  Provider Name:  Dr. Andrew Ross  DOS 6/01/02, Claim/Services:  CPT Code  Modifier  84460  Mod CF  82247  Mod CF  82248  Mod CF  82040  Mod CD  84075  Mod CD  84450  Mod CD  ACTION:   6 services total, 3 non- composite rate tests and 3 composite rate tests; 3/6 = 50%, therefore no payment.  Example 5:  ( A/B MAC (B)  Processing Example Only)  Payment for first claim, second claim creates a no payment status for either claim.  Provider Name:  Dr. Andrew Ross  DOS 6/01/06, Claim/Services -  First claim  CPT Code  Modifier  84460  Mod CF  82247  Mod CF  82248  Mod CF  ACTION:  3 services total, 3 non- composite rate tests, 0 composite rate tests beyond the frequency, and 0 composite rate tests, 0/3 =  0%, therefore ATP 03