evekhm/cms_iom_500 huggingface dataset:
(Medicare Claims Processing Manual)
EXAMPLE 2:   As of July 22, 1999, the hospital had an arrangement with an independent laboratory, laboratory A, under which that laboratory billed the A/B MAC (B) for the TC of physician pathology service to hospital inpatients or outpatients.  In 2001, the hospital enters into an arrangement with a different independent laboratory, laboratory B, under which laboratory B wishes to bill its A/B MAC (B) for the TC of physician pathology services to hospital inpatients or outpatients.  Because the hospital is a covered hospital, independent laboratory B can bill its A/B MAC (B) for the TC of physician pathology services to hospital inpatients or outpatients.  If the arrangement between the independent laboratory and the covered hospital limited the provision of TC physician pathology services to certain situations or at particular times, then the independent laboratory can bill the A/B MAC (B) only for these li mited services.   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.
(Medicare Claims Processing Manual)
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.
(Medicare Claims Processing Manual)
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.
(Medicare Claims Processing Manual)
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.
(Medicare Claims Processing Manual)
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)
(Medicare Claims Processing Manual)
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
(Medicare Claims Processing Manual)
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.
(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.
(Medicare Claims Processing Manual)
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:
(Medicare Claims Processing Manual)
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.
(Medicare Claims Processing Manual)
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)
(Medicare Claims Processing Manual)
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.
(Medicare Claims Processing Manual)
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.