(Medicare Claims Processing Manual)

The shared system provides for this processing.  100.4 - Not Otherwise Classified Clinical Laboratory Tests  (Rev. 1, 10- 01-03)  The following codes for unlisted or not otherwise classified (NOC) clinical laboratory tests are not subject to the NLA:   81099 87999 84999 88299 85999 89399 86999  The NOC codes shall suspend for review and the A/B MAC (B) shall determine a price for them.   100.5 - Other Coding Issues  (Rev. 1, 10- 01-03)  100.5.1 - Tests Performed More Than Once on the Same Day  (Rev. 1, 10- 01-03) PM AB -98-7  When it is necessary to obtain multiple results in the course of treatment, the modifiers 59 or 91 are used to indicate that a test was performed more than once on the same day for the same patient.  The 91 modifier is used for laboratory tests paid under the clinical laboratory fee schedule.   These modifiers may be used to indicate that a test was performed more than once on the same day for the same patient, only when it is necessary to obtain multiple results in the course of treatment.  These modifiers may not be used when tests are rerun to confirm initial results; due to testing problems with specimens and equipment; or for any other reason when a normal, one -time, reportable result is all that is required.  These modifiers may not be used when there are standard HCPCS codes available that describe the series of results (e.g., glucose tolerance tests, evocative/suppression testing, etc.).  These modifiers may be used only for laboratory tests paid under the clinical laboratory fee schedule.   Improper use of modifiers is likely to indicate a fraudulent or abusive circumstance.  When informing laboratories of the availability of modifiers, A/B MACs (B) are to emphasize that these modifiers have very narrow application and that any evidence of excessive use will be referred to A/B MAC (A) or (B) Program Integrity Unit for further review.   100.6 - Pricing Modifiers  (Rev. 2487, Issued: 06- 08-12, Effective: 01 -01-11, Implementation: 06- 19-12)  PM A -03-033  Prior to January 1, 2011  Three pricing modifiers discretely identify the different payment situations for ESRD Automated Multi- Channel Chemistry (AMCC) tests.  The physician that orders the tests is responsible for identifying the appropriate modifier when ordering the tests.  The modifiers are in the following listing:    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    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    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   The ESRD clinical laboratory tests identified with modifiers CD, CE, or CF may not be billed as organ or disease panels.  Effective October 1, 2003, all ESRD clinical laboratory tests must be billed individually.   Effective January 1, 2011  With the implementation of the ESRD PPS, effective for claims with dates of service on or after January 1, 2011, all ESRD -related laboratory services are included in the ESRD PPS base rate.  If the ESRD facility needs to report a lab service that was not related to the treatment of ESRD, they must include the modifier AY to indicate the item or service is not f or the treatment of ESRD.  Modifiers CD, CE, and CF (also known as the 50/50 rule modifiers) are no longer valid for use on independent laboratory claims.  Effective January 1, 2012, A/B MACs (B) shall allow organ disease panel codes (i.e., HCPCS codes 80047, 80048, 80051, 80053, 80061, 80069, and 80076) to be billed by independent laboratories for AMCC panel tests furnished to ESRD eligible beneficiaries.   For more information regarding billing of AMCC tests for ESRD beneficiaries, see Section 40.6.1 of this manual.  110 - Coordination Between A/B MACs (B) and Other Entities  (Rev. 1, 10- 01-03) B3-5114.1  110.1 - Coordination Between A/B MACs (B)  and A/B MACs (A) /RRB  (Rev. 1, 10- 01-03)  The A/B MAC (B) furnishes copies of fees that are locally established under the fee schedules (price code = 22) to A/B MACs (A) and to the RRB Specialty MAC (S MAC).  The A/B MAC (B) must provide updates at least 30 days prior to the A/B MAC (B)s schedule d implementation of the update.  The A/B MACs (A) add these fees to system fee schedule tables to use in paying for hospital laboratory tests performed for both outpatients of the hospital and persons who are not patients of the hospital.  The RRB S MAC us es the fee schedules in paying for outpatient clinical laboratory tests.  A/B MACs (A) and the RRB may consult with A/B MACs (B) on filling gaps in fee schedules for tests where the A/B MAC (B) may not have established an amount.  If an A/B MAC (A) or the RRB S MAC has bills for payment on laboratory tests for which the A/B MAC (B) has not furnished amounts, it consults with the A/B MAC (B).  If necessary the A/B MAC (B) consults with other nearby A/B MACs (B).   110.2 - Coordination With Medicaid  (Rev. 1, 10- 01-03)  A/B MACs (B) furnish copies of the fee schedules and the annual update (including NLAs where applicable) to State agencies (SAs).  A/B MACs (B) provide updates to SAs at least 30 days prior to the scheduled implementation.  To obtain Federal matching funds  for clinical laboratory services, State Medicaid agencies may not pay more than Medicare pays for the services and specimen collections.   Since the fee schedule provisions were implemented on a carrier wide basis, a State may have had more than one carrier servicing Medicare beneficiaries residing in the State.  A Medicaid agency for such a State may, if it deems necessary, use the fee sched ules of either one or both of the A/B MACs (B) to meet the Federal fund- matching requirement.  State Medicaid agencies may consult with ROs concerning the fee schedule, the NLAs, and specimen collection provisions.  110.3 - Coordination With A/B MACs (A)  and Providers (Rev. 1, 10- 01-03) HO- 437, A3- 3628  There may be procedures hospitals bill for outpatients that are not included in the fee schedule.  Where gaps occur, hospitals should work out procedures with the A/B MAC (A) so that the hospital can secure the missing information promptly.  Price Codes established by the A/B MAC (B) to fill gaps are valid until replaced by the earlier of permanent codes or the next annual update.   110.4 - A/B MAC (B)  Contacts With Independent Clinical Laboratories  (Rev. 1, 10- 01-03) B3-2070.1.F   An important role of the A/B MAC (B) is as a communicant of necessary information to independent clinical laboratories.  Failure to inform independent laboratories of Medicare regulations and claims processing procedures may have an adverse effect on prose cution of laboratories suspected of fraudulent activities with respect to tests performed by, or billed on behalf of, independent laboratories.  United States Attorneys often must prosecute under a handicap or may refuse to prosecute cases where there is n o evidence that a laboratory has been specifically informed of Medicare regulations and claims processing procedures.  To assure that laboratories are aware of Medicare regulations and A/B MAC (B)s policy, notification must be sent to independent laboratories when any changes are made in coverage policy or claims processing procedures.  Additionally, to completely document efforts to fully inform independent laboratories of Medicare policy and the laboratorys responsibilities, previously issued newsletters should be periodically re -issued to remind laboratories of existing requirements.   Some items which should be discussed are the requirements to have the same charges for Medicare and private patients, to document fully the medical necessity for collection of specimens from a skilled nursing facility or a beneficiarys home, and, in cases  when a laboratory service is referred from one independent laboratory to another independent laboratory, to identify the laboratory actually performing the test.  Additionally, when A/B MAC (B) professional relations representatives make personal contacts with particular laboratories, they should prepare and retain reports of contact indicating dates, persons present, and issues discussed.  120 - Clinical Laboratory Services Based on the Negotiated Rulemaking  (Rev. 1, 10- 01-03) PM AB -02-129  Section 4554(b)(1) of the Balanced Budget Act (BBA), Public Law 105- 33 mandated the use of a negotiated rulemaking committee to develop national coverage and administrative policies for clinical laboratory services payable under Part B of Medicare.  The BBA required that these national policies be designed to promote program integrity and national uniformity; and to simplify administrative requirements with respect to clinical diagnostic laboratory services payable under Part B.   These changes apply to every diagnostic clinical laboratory service that is payable under Medicare Part B.  Neither the place where the service was performed, nor the type of A/B MAC (A) or (B) that will process the request for payment, has any effect on t he applicability of these policies.  A clinical laboratory service done in a hospital laboratory, independent laboratory, physician/practitioner office laboratory or other type of CLIA approved laboratory service is subject to these administrative policies .  The final rule did not affect the requirement that all physician claims must have a diagnosis.  If a physician submits a claim for a service performed in a physician office laboratory, that claim is considered a physician claim and must meet the requirements for physician claims.   120.1 - Negotiated Rulemaking Implementation  (Rev. 1769, Issued: 07- 10-09, Effective/Implementation: 07- 31-09)  The following requirements apply to service providers:    The date of service should be reported as the date of specimen collection.   The person obtaining the specimen must furnish the date of collection for the specimen to the entity billing Medicare.    For specimen collections that span more than a 24 -hour period, the date of service should be reported as the date the collection began.   For laboratory tests that require a specimen from stored collections, the date of service should be defined as the date the specimen was obtained from the archives.    If a situation occurs that does not correspond to the two situations described, the A/B MAC (A) or (B) will submit the question to the RO with the appropriate documentation.  The RO will contact the Division of Supplier Claims Processing in CMS, which will  serve as the point of contact.   Matching of Diagnosis to Procedure   During claims processing and adjudication, the A/B MAC (A) or (B) adheres to the following:    If there is a LMRP or NCD for one or more of the services included on the claim, the A/B MAC (A) or (B) reviews all of the diagnosis codes in making a determination regarding medical necessity of the service.    Even though a claim matches diagnosis to procedure in accordance with an NCD, other rules of adjudication may apply, which could result in denial.   Diagnoses are required on all claims.   Physicians Reporting Diagnosis Codes When A Diagnostic Test Is Ordered  Section 4317 of the Balanced Budget Act of 1997 provides, with respect to diagnostic laboratory and certain other services, that if the Secretary (or A/B MAC (A) or (B) of the Secretary) requires the entity furnishing the services to provide diagnostic or  other medical information to the entity, the physician or practitioner ordering the service shall provide that information to the entity at the time the service is ordered by the physician or practitioner.  A laboratory or other provider must report on a  claim for Medicare payment the diagnostic code(s) furnished by the ordering physician.  In the absence of such coding information, the laboratory or other provider may determine the appropriate diagnostic code based on the ordering physicians narrative diagnostic statement or seek diagnostic information from the ordering physician/practitioner.  However, a laboratory or other provider may not report on a claim for Medicare payment a diagnosis code in the absence of physician -supplied diagnostic information supporting such code.  Clarification of the Use of the Term Screening or Screen"   The final rule clarifies that effective February 21, 2002, the use of the term screening or screen in CPT code descriptor does not necessarily describe a test performed in the absence of signs and symptoms of illness, disease or condition.  A/B MACs (A ) and (B) do not deny a service based solely on the presence of the term screening or screen in the descriptor.