(Medicare Claims Processing Manual)

Example 5:  continued ( A/B MAC (B)  Processing Example Only)  Provider Name:  Dr. Andrew Ross  DOS 6/01/06, Claim/Services - Second claim  CPT Code  Modifier  82040  Mod CD  84075  Mod CD  84450  Mod CD  ACTION:   An additional 3 services are billed, 0 non-composite rate tests, 8 composite rate tests beyond the frequency, 3 composite rate tests.  For both claims there are 6 services total, 3 non- composite rate tests and 3 composite rate tests; 3/6 = 50% U> U 50%, therefore no payment.  An overpayment should be recovered for the ATP 03 payment on the first claim.  40.6.2 - Claims Processing for Separately Billable Tests for ESRD Beneficiaries  (Rev. 1655, Issued: 12- 31-08, Effective: 01-01-09, Implementation: 02 -02-09)  Clinical laboratory tests can be performed individually or in predetermined groups on automated profile equipment.  If a test profile is performed see 40.6.1.  If a clinical laboratory test is performed individually, see 40.6.2.1 .  However the tests are performed in the laboratory setting, the services must be billed individually, and must not be billed in a group as an organ or disease panel.  40.6.2.1 - Separately Billable ESRD Laboratory Tests Furnished by Hospital-Based Facilities (Rev. 3425, Issued: 12- 18-15, Effective: 01-01-16, Implementation: 01-04-16)  Independent laboratories and independent dialysis facilities with the appropriate clinical laboratory certification in accordance with CLIA may be paid for ESRD  clinical  laboratory tests that are separately billable.  The laboratories and independent dialysis facilities are paid for separately billable clinical laboratory tests according to  the Medicare laboratory fee schedule for independent laboratories.  (See 40.3 for details on Part B hospital billing rules for laboratory services.)   Hospital-based laboratories providing separately billable laboratory services to dialysis patients of the hospitals dialysis facility or any other dialysis facility bill and are paid  in accordance with the hospital outpatient laboratory provisions in Chapter 16, section 40.3.  40.6.2.2 - Reserved  (Rev. 1655, Issued: 12- 31-08, Effective: 01-01-09, Implementation: 02-02-09)  40.6.2.3 - Skilled Nursing Facility (SNF) Consolidated Billing (CB) Editing and Separately Billed ESRD Laboratory Test Furnished to Patients of Renal Dialysis Facilities (Rev. 4227, Issued: 02- 01-2019, Effective: 07-01-19, Implementation: 07-01-19 )   Effective April 1, 2003, for dates of service (DOS) on or after April 1, 2001 and ending June 30, 2019:    Effective April 1, 2003, for DOS on or after April 1, 2001, CWF will not apply the SNF CB edits to line items that contain the CB modifier.  A provider or supplier may use the CB modifier only when it has determined that:  (a) the beneficiary has ESRD en titlement, (b) the test is related to the dialysis treatment for ESRD, (c) the test is ordered by a doctor providing care to patients in the dialysis facility, and (d) the test is not included in the dialysis facilitys composite rate payment.   Those diagnostic tests that are presumptively considered to be dialysis-related and, therefore, appropriate for submission with the CB modifier are identified in Exhibit 1.  This list was not designed as an all- inclusive list of Medicare covered diagnos tic services.  Additional diagnostic services related to the beneficiarys ESRD treatment/care may be considered dialysis -related.  However, if these services are not included in our listing, the A/B MAC (A) may require supporting medical documentation.  When a hospital laboratory is billing for laboratory services ordered by an ESRD facility and the patient (beneficiary) is a SNF resident under a Part A stay, the hospital laboratory must use the CB modifier for those services excluded from consolidated billing.   Beneficiaries in a SNF Part A stay are eligible for a broad range of diagnostic services as part of the SNF Part A benefit.  Physicians ordering medically necessary diagnostic test that are not directly related to the beneficiarys ESRD are subject to the SNF consolidated billing requirements.  Physicians may bill the A/B MAC (B) for the professional component of these diagnostic tests.  In most cases, however, the technical component of diagnostic tests is included in the SNF PPS rate and is not separately billable to the A/B MAC (B).  Physicians should coordinate with the SNF in ordering such tests since the SNF will be responsible for bearing the cost of the technical component.  Effective for DOS on or after July 1, 2019:  Effective for claims with DOS on or after July 1, 2019, the CB modifier, previously used by Independent Labs when billing for separate payment outside the SNF Consolidated Billing for ESRD dialysis -related lab services, is no longer applicable.   With the January 1, 2011 implementation of the ESRD PPS and effective for DOS on or after July 1, 2019, Exhibit 1 is no longer recognized as the list of separately billable ESRD dialysis- related services. Instead, a list of the recognized renal dialysis la boratory tests that are subject to Part B ESRD PPS consolidated billing requirements, are considered routinely performed for the treatment of ESRD, and are not separately paid when provided to ESRD beneficiaries by providers or suppliers other than the ESR D facility, is located on the CMS Website: https://www.cms.gov/Medicare/Medicare- Fee-for-Service-Payment/ESRDpayment/Consolidated_Billing.html .    The list of renal dialysis laboratory tests provided in the Part B ESRD PPS consolidated billing requirements is not an all -inclusive list. For laboratory tests not included in this list, the distinction of what is considered to be a renal dialysis laborat ory test is a clinical decision determined by the ESRD beneficiarys ordering practitioner. If any laboratory test is ordered for the treatment of ESRD, then the laboratory test is considered to be included in the ESRD PPS, is the responsibility of the ESR D facility and is excluded from the SNF PPS. More information regarding renal dialysis services payable under the ESRD PPS is available in Pub. 100 -02, chapter 11.   Beneficiaries in a SNF Part A stay are eligible for a broad range of diagnostic services as part of the SNF Part A benefit.  Physicians ordering medically necessary diagnostic tests that are not directly related to the beneficiarys ESRD are subject to the SNF consolidated billing requirements.   Physicians may bill the A/B MAC (B) for the professional component of these diagnostic tests.  In most cases, however, the technical component of diagnostic tests is included in the SNF PPS rate and is not separately billable to the A/B MAC (B).  Physici ans should coordinate with the SNF in ordering such tests since the SNF will be responsible for bearing the cost of the technical component.   A patients physician or practitioner may order a laboratory test that is included on the list of items and services subject to consolidated billing edits for reasons other than for the treatment of ESRD. When this occurs, the SNF CB applies.   40.7 - Billing for Noncovered Clinical Laboratory Tests  (Rev. 1, 10-01-03) B3-5114.1  Ordinarily, neither a physician nor a laboratory bills the Medicare Program for noncovered tests.  However, if the beneficiary (or his/her representative) contends that a clinical laboratory test which a physician or laboratory believes is noncovered may be covered, the physician or laboratory must file a claim that includes the test to effectuate the beneficiarys right to a Medicare determination.  The physician or laboratory annotates the claim that he/she believes that the test is noncovered and is submitting it at the beneficiarys insistence.  Before furnishing a beneficiary a test which the physician or laboratory believes is excluded from coverage as not reasonable and necessary (rather than excluded from coverage as part of a routine physical check -up), the physician or laboratory must obtain a signed Advanced Benefici ary Notice (ABN) from the beneficiary (or representative) that the physician or laboratory has informed him/her of the noncoverage of the test and that there will be a charge for the test.  This protects the physician or laboratory against possible liability for the test under the limitation of liability provision.   See Chapter 30, regarding Advance Beneficiary Notices (ABN) and demand bills.  40.8 - Date of Service (DOS) for Clinical Laboratory and Pathology Specimens  (Rev. 4481; Issued: 12- 20-19, Effective: 01-01-20, Implementation: 01-23-20)  The DOS policy for either a clinical laboratory test or the technical component of physician pathology service is as follows:   General Rule:  The DOS of the test/service must be the date the specimen was collected.   Variation : If a specimen is collected over a period that spans two calendar days, then the DOS must be the date the collection ended.   Exceptions: The following three exceptions apply to the DOS policy for either a clinical laboratory test or the technical component of physician pathology service:  A. DOS for Tests/Services Performed on Stored  Specimens:   In the case of a test/service performed on a stored specimen, if a specimen was stored for less than or equal to 30 calendar days from the date it was collected, the DOS of the test/service must be the date the test/service was performed only if:   The test/service is ordered by the patients physician at least 14 days following the date of the patients discharge from the hospital;   The specimen was collected while the patient was undergoing a hospital surgical procedure;   It would be medically inappropriate to have collected the sample other than during the hospital procedure for which the patient was admitted;    The results of the test/service do not guide treatment provided during the hospital stay; and   The test/service was reasonable and medically necessary for treatment of an  illness.   If the specimen was stored for more than 30 calendar days before testing, the specimen is considered to have been archived and the DOS of the test/service must be the date the specimen was obtained from storage.   B. DOS for Chemotherapy Sensitivity Tests/Services Performed on Live Tissue:   In the case of a chemotherapy sensitivity test/service performed on live tissue, the DOS of the test/service must be the date the test/service was performed only if:    The decision regarding the specific chemotherapeutic agents to test is made at least 14 days after discharge;    The specimen was collected while the patient was undergoing a hospital surgical  procedure;    It would be medically inappropriate to have collected the sample other than during the hospital procedure for which the patient was  admitted;    The results of the test/service do not guide treatment provided during the hospital stay;  and   The test/service was reasonable and medically necessary for treatment of an  illness.   For purposes of applying the above exception, a chemotherapy sensitivity test is defined as a test that requires a fresh tissue sample to test the sensitivity of tumor cells to various chemotherapeutic agents. CMS identifies such tests through program instructions issued to the Medicare Administrative Contractors (MACs).   C. DOS for Advanced Diagnostic Laboratory Tests and Molecular Pathology Tests:   In the case of a molecular pathology test performed by a laboratory other than a blood bank or center, or a test designated by CMS as an ADLT under paragraph (1) of the definition of advanced diagnostic laboratory test in 42 CFR 414.502, the DOS must be the date the test was performed only if:    The test was performed following a hospital outpatients discharge from the        hospital  outpatient department;    The specimen was collected from a hospital outpatient during an encounter                      (as both are defined in 42 CFR  410.2);    It was medically appropriate to have collected the sample from the hospital outpatient during the hospital outpatient encounter;    The results of the test do not guide treatment provided during the hospital outpatient  encounter; and   The test was reasonable and medically necessary for the treatment of an  illness.   For the purpose of section 40.8.C, a  blood bank or center means an entity whose primary function is the performance or responsibility for the performance of, the collection, processing, testing, storage and/or distribution of blood or blood components intended for transfusion and transplantation.    50 - A/B MAC (B)  Claims Processing  (Rev. 1, 10- 01-03)  50.1 - Referring Laboratories  (Rev. 85, 02- 06-04) B3-5114.1