(Medicare Claims Processing Manual)

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.   3. Process Claims.  For claims with dates of service prior to January 1, 2019, t he processes shown below (A -K) should be followed to price and pay claims for automated panels (as defined in HCPCS) and individual tests.  This does not replace or abridge any current procedures in place concerning the adjudication of claim.  This is a general procedure for combining these services to attain the lowest pricing outcome.  This display is an example only.  System maintainers have the flexibility to vary these procedures as long as they attain the same result.   A. Unbundle all panels to single lines representing individual automated multi -channel chemistry (AMCC) tests, and identify duplicate tests within the claim.  On concurrently processed claims, determine the total amount payable based on the combination of all AMCC tests billed by the same laboratory, for the same beneficiary, and for the same date of service.   B. Check history for laboratory AMCC services provided by the same provider, to the same beneficiary, on the same day.  Unbundle any panels.  Identify duplicate services.  Aggregate all nonduplicate services for pricing (include the submitted charge and paid amounts for both individually or paneled billed claims).  If a single organ disease panel or a single chemistry panel contains the only AMCC test claims for that date of service, adjudicate as billed.   C. Compare each lines submitted charge to the fee schedule for that code (including automated tests retrieved from history).   D. Sum the comparisons of the line by line.  E. Obtain the fee for all AMCC tests as a panel including all services in history.  If organ disease (OD) panels are involved, this amount will include fees for nonautomated tests included in the OD panel.   F. Carry forward the lesser of items D or E.   G. For steps A -C above, include the following calculations to price the claim by locality, using the fee schedule amount for each locality, when one or more test has been referred to another laboratory for processing:   Use the total number of allowable AMCC tests  (both referred and nonreferred) to calculate the amount payable for each test.  For example, if three tests are performed within the A/B MAC (A)s or (B)s jurisdiction, and two are referred to another laboratory for processing, first determine the amount  payable for the five tests in each payment jurisdiction.  Divide the total fee schedule amount for all tests being priced by the total number of allowable AMCC tests (in this example, five tests).  The result is  the unit price for each test.  Multiply this result by the total number of AMCC tests performed within each pricing jurisdiction.  (In this example, three tests were performed in jurisdiction 1 and two tests were performed in jurisdiction 2).  Repeat this  process for each pricing jurisdiction.  In this example, there are two pricing jurisdictions.  In jurisdiction 1, the amount payable is calculated by dividing the total fee schedule amount for jurisdiction 1 by five, and multiplying the result by three.  Similarly, the amount payable for jurisdiction 2 is calculated by dividing the total fee schedule amount for jurisdiction 2 by five, and multiplying the result by two.  Sum the two results (i.e., jurisdiction 1 amount + jurisdiction 2 amount).  Compare thi s calculated amount to the submitted charges for the AMCC tests to determine the amount payable.  (The amount payable is the lower of the fee schedule amount versus the submitted charges.)   H. Carry forward the lesser of the fee schedule amount versus the submitted charges, as determined in item G.   I. Subtract from item H any previous laboratory AMCC test (individual or paneled) or organ disease panel containing automated test payments.  If nothing is payable on the claim, allow it with no payment.   J. The amount payable is the total payable based on the combination of current and previously processed claims, less the total amount paid on the previous claim(s).  K. If a claim is a CLIA reject from the CWF, recycle that claim through the payment process to recalculate payment.   (NOTE:   These calculations are provided as an example only.  A/B MACs (A) and (B) and shared system maintainers have the flexibility to vary these procedures as long as they attain the same result.)   If none of the AMCC tests have been referred to another laboratory for processing, A/B MACs (A) and (B) should exclude item G in calculating the amounts payable for individual AMCC tests and AMCC panels.  90.3.1 - History Display  (Rev. 4299, Issued: 05- 03-19, Effective: 01 -01-19, Implementation: 10- 07-19)  Prior to January 1, 2018, when displaying claims payment for each CPT code in history, A/B MACs (A) and (B) apply the following rules:   1. If all component tests of any panel are allowed because the individual line item comparison is less than the fee (as determined in item C above), record the panel codes as determined on the line -by-line comparison.   2. If all component tests are paid based on the panel price, allocate the current payment proportionate to the amount submitted for each CPT code.   3. If any panel tests will be denied or there are previously paid automated laboratory tests (as indicated by a check of beneficiary history), allocate the current payment amount by allowed line proportionate to what was submitted for the current claim being processed.   For administration of pricing requirements and/or invalid coding policies, A/B MACs (A) and (B) must establish a processing sequence for concurrently processed claims based on ascending order of internal control number (ICN).  In the case of pricing, they must process the first claim (i.e., lower CN) based solely on the billed codes on that claim, process the second claim based on a combination of the billed codes on both claims and pay the balance due after subtracting the amount paid on the first cl aim.  In the case of unacceptable code combinations, A/B MACs (A) and (B) must deny the second claim.   90.3.2 - Medicare Secondary Payer  (Rev. 1, 10- 01-03)  When processing claims involving Medicare secondary payer (MSP), A/B MACs (B) should use the MSP payment formula as follows:   When Medicare is secondary, Medicare pays the lowest of:    The actual charge less the primary payment;   The amount Medicare would pay if primary; or   The higher of the Medicare or primary allowable less the primary payment.  The two -step pricing comparison described above is required for calculating MSP amounts.  90.4 - Evaluating the Medical Necessity for Laboratory Panel CPT Codes (Rev. 1, 10- 01-03) PM-B-98-1  The American Medical Associations (AMA) 1998 edition of the Current Procedural Terminology (CPT) establishes three new and one revised Organ or Disease Oriented laboratory panels.  Since these panels are composed of clinically relevant groupings of automa ted multi- channel tests there is a general presumption of medical necessity.  If A/B MACs (B) suspect abuse of the new panel codes, they should review such claims.  Should an A/B MAC (B) determine the need to develop a LMRP for laboratory panel codes, the A/B MAC (B) should develop such a policy at the panel code level.  As appropriate, an A/B MAC (B) may review the panel and deny component tests on a case -by-case basis or evaluate the need for the component level test.   90.5 - Special Processing Considerations  (Rev. 4299, Issued: 05- 03-19, Effective: 01 -01-19, Implementation: 10- 07-19) PM AB -97-17  To order any of the 23 automated tests, a physician may select individual tests or the panel.  A physician may order a mix of panels and individual tests.  The physician should review what tests are in each panel and not order individual tests that might duplicate tests in the panel.  Medicare denies duplicate tests.   Specialists are not, based on their specialty, restricted to ordering certain panels or individual tests.  The physician (general practitioner or specialist) should identify which tests he/she requires; and, if the tests match a grouping, order the appropr iate panel.    Claimants should use the QP modifier with the single ordering of tests or when a single code is available for groupings of tests.  This modifier indicates that the claimant has documentation on file showing that the laboratory test(s) was ordered individua lly or ordered as a CPT -recognized panel   100 - CPT Codes Subject to and Not Subject to the Clinical Laboratory Fee Schedule  (Rev. 1, 10- 01-03) HO- 437, A3- 3628, B3- 5114.1  For fee schedule purposes, clinical laboratory services include most laboratory tests listed in codes 80048- 89399 of CPT -1996.  The CMS issues an update to the laboratory fee schedule each year, with information about whether prices have been determined by CMS or whether the individual A/B MAC (B) must determine the allowable charge.   Codes not included are not paid under the laboratory fee schedule but may be paid under the MPFS if covered for Medicare.   100.1 - Deleted - Held for Expansion  (Rev. 1, 10- 01-03)  100.2 - Laboratory Tests Never Subject to the Fee Schedule  (Rev. 1, 10- 01-03)  Some CPT codes in the 80000 series are not clinical laboratory tests and are therefore never subject to fee schedule limitations.  Some of these codes are exempted because they are not clinical laboratory services.  They include codes for procedures, servi ces, blood products and auto- transfusions.  They include codes such as whole blood, various red blood cell products, platelets, plasma, and cryoprecipitate.  Other codes for tests primarily associated with the provision of blood products are also not consi dered to be clinical tests.  Such tests identify various characteristics of blood products, but are not diagnostic in nature.  These include various blood cross matching techniques.  If they are covered, Medicare pays exclusion codes under the MPFS, reasonable charges, reasonable costs, or OPPS as applicable.   100.3 - Procedures Not Subject to Fee Schedule When Billed With Blood Products  (Rev. 1, 10- 01-03)  The following codes are not subject to fee schedule limitations when submitted for payment on the same bill with charges for blood products.  Rather, assume they are to be used for blood matching and not for diagnostic purposes.   Codes: 86901, 86905, 86930- 86932, 86920- 86922, 86890, 86870, 86891, 86880- 86886, 86971, and 86930.  If no blood product is provided and billed for on the same claim, assume the codes are diagnostic and subject to the clinical laboratory fee schedule.   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.