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CodeMap® 05/01/2002 - CodeMap® Quarterly Reports, Volume I, No. 2 CodeMap®-05/01/2002 - CodeMap® Quarterly Reports, Volume I, No. 2 Archive

CodeMap Reports
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Coding, Reimbursement and Compliance Information
Volume I, No. 2, May 1, 2002
Published by CodeMap, Barrington, IL  847-381-5465
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IN THIS ISSUE:

  • Reimbursement Forum: Clinical Pathology Consultations and Clinical Laboratory Intepretations                                                                       
  • Compliance Issues: National Coverage Determinations and Local Medical Review Policies                                                                                                
  • Coding Basics: Medicare Coding and Reimbursement for Screening Mammography                                                                             
  • Q&A: The Cost of Compliance Training
  • Codemap Compliance Tools

___________________________________________________
Welcome to CodeMap Reports, your source for information and comment on how to get paid correctly and remain in compliance with Medicare rules and regulations.  Our focus is primarily on issues involving Medicare Part B payment for laboratory, pathology and radiology services plus the Hospital Outpatient Prospective Payment System (HOPPS).  

Please feel free to let us know what you think of this newsletter by sending us an e-mail at info@codemap.com. If you have any questions or suggestions for future articles please contact us either by email or phone.

Charles B. Root, Ph.D., Editor

___________________________________________________
Clinical Pathology Consultations, Clinical Laboratory Interpretations and Why You May Not Be Paid for Either Because of CCI Edits.

A clinical pathology consultation is defined in the CPT as a service rendered by a pathologist in response to a request from an attending physician related to test results that require additional medical interpretative judgment.  A written report must be included. Clinical Laboratory Interpretations are also reimbursed by Medicare.  Interpretations are only allowed for the 16 clinical laboratory tests listed below when requested by the attending physician. Such interpretations must also require medical judgment by the consulting pathologist and include a written report.

83020-26: Hemoglobin electrophoresis

83912-26: Molecular diagnostics, interpretation and report

84165-26: Protein, electrophoresis

84181-26: Protein by Western blot

84182-26: Protein by Western blot, immunological probe

85390-26: Fibrinolysins screen

85576-26: Platelet aggregation

86255-26: Fluorescent non-infectious agent antibody screen

86256-26: Fluorescent non-infectious agent antibody titer

86320-26: Immunoelectrophoresis, serum

86325-26: Immunoelectrophoresis, other fluids

86327-26: Immunoelectrophoresis, crossed, 2-dimensional assay

86334-26: Immunofixation electrophoresis

87164-26: Dark field examination, any source

87207-26: Smear, special stain for inclusion bodies or intracellular parasites

89060-26: Crystal identification by light microscopy

Clinical pathology consultations are reported using CPT codes 80500 and 80502. Clinical laboratory interpretations are reported by appending a 26 modifier (professional component)  to the CPT code for the test being interpreted. For example, Hemoglobin fractionation and quantitation by electrophoresis would be reported using 83030 for the assay and 83030-26 for the interpretation.

Denials for consultations and interpretations can arise when Medicare employs Correct Coding Initiative (CCI) edits that apply to many laboratory CPT codes.  For example, almost all coagulation assays are defined by the CCI as including pathology consultation codes 80500 and 80502.  Thus, a consultation submitted with almost any clotting factor CPT code will be denied as a component of the test code. It is not clear why some clinical tests are assumed to include a written consultation and some are not.  For example, a consultation is allowed for a sedimentation rate (85651 or 85652) but not for a prothrombin time when neither test is usually reported with a written interpretation by a pathologist.

To further complicate things, except for the 18 tests mentioned above, Medicare considers reimbursement for the interpretation of all other tests on the laboratory fee schedule to be included in the evaluation and management services (office visit code) provided by the attending physician.

In summary, when a consultation/interpretation is requested, use the 26 modifier when appropriate and check the CCI edits to make sure the service is not considered part of the clinical lab service. If it is, make sure the attending physician obtains a signed Advance Beneficiary Notice from the patient so the lab can bill the patient if the service is denied.

____________________________________________________________
 National Coverage Determinations and Local Medical Review Policies

As most laboratory professionals already know, CMS has developed 23 National Coverage Determinations (NCDs) for commonly ordered laboratory tests. NCDs are similar to, and will eventually replace, many Local Medical Review Policies (LMRPs). Both LMRPs and NCDs typically contain information concerning indications and limitations of coverage, frequency limitations, and most importantly, covered diagnosis codes (ICD-9 codes). CMS developed NCDs with the help of industry and provider representatives in an effort to standardize medical necessity rules across the country.

Presently, providers must comply with medical necessity rules from LMRPs that differ from state to state. Each Medicare carrier has the discretion to develop LMRPs for any test or procedure they feel is being over utilized or abused. Once a LMRP is in effect, providers must submit one of the covered ICD-9 codes listed in the LMRP or the claim for the test will be denied as not medically necessary. Because each Medicare Carrier develops its LMRPs independently, the list of covered ICD-9 codes for a particular test can differ significantly from state to state.

NCDs, which also contain covered ICD-9 codes, will apply to all laboratories in all states exactly the same way, but only for the 23 tests and procedures covered by the NCDs. Providers must be aware that after the implementation date of the NCDs, which is November 25, 2002, medical necessity rules for lab tests will be included in both LMRPs and NCDs. The implementation of NCDs will not result in the elimination of all LMRPs. While it is true that NCDs will supersede any existing LMRPs concerning the same test or procedure, Medicare carriers will still possess the power to retain existing LMRPs and develop new LMRPs concerning tests and procedures not covered by NCDs.

The implementation of NCDs might actually increase the number of coverage policies a laboratory must follow depending on the number of LMRPs published by their local carrier that will remain in effect. The bottom line is that providers will now have to obtain medical necessity information from both CMS and their Medicare Carrier.

Publisher’s Note: MCF Compliance has expanded its Medical Necessity Guide to include National Coverage Determinations as well as Local Medical Policies. Order yours soon to ensure your laboratory has comprehensive and accurate medical necessity information before November 25, 2002.

For more information: http://www.codemap.com/mng

___________________________________________________________
 Medicare Coding and Reimbursement for Screening Mammography

Prior to Jan 1, 2002, Medicare paid for screening mammography under a separate payment system with a maximum payment of $69.23 for all localities. Beginning Jan 1, 2002, screening mammography, including digital studies, is now covered under the physician fee schedule.  This means that payment will vary from region to region to reflect differences in physician expense and malpractice rates for screening mammography as well as diagnostic mammography (which has always been covered under the physician fee schedule). Diagnostic services are performed for patients presenting with signs or symptoms of disease, while screening services are performed for patients with no evidence of disease or disorder.

The new relative value units assigned to bilateral screening mammography (CPT code 76092) are the same as for diagnostic mammography and result in reimbursement of about $80.70 unadjusted for geographic differences.

 In summary, the following codes and Medicare payments (unadjusted for geographical differences) apply.

76092: screening mammography, bilateral: $80.70.

 Digital screening mammography is reported using the following HCPCS codes:

G0202: screening mammography, producing direct digital image, bilateral, all views: $126.30.

G0204: screening mammography, film processed to produce digital images, analyzed for potential abnormalities, bilateral, all views: $133.60.

The following add-on code for computer-aided lesion detection can be used with CPT Code 76092. This is a payable diagnostic procedure since it applies to an abnormal finding from a screening mammogram.

76085: Digitization of film radiographic images with computer analysis for lesion detection and further physician review for interpretation, screening mammography: $14.12.

When professional and technical components are billed separately for the above services, the technical component is approximately two thirds of the total reimbursement and the professional component one third.

Remember, your CodeMap Medicare Reimbursement Guide provides the exact Medicare payments for your locality including both the technical and professional components. 

____________________________________________________________
Q&A: The Cost of Compliance Training

We received several questions concerning compliance training similar to those below.

Question 1: I am the supervisor of a physician office laboratory operated by a 7-doctor practice. In addition, I was recently named the compliance officer of the practice. I have developed a compliance program with the limited resources available to me, but I am still at a loss on how to perform and document compliance training for our employees. Any suggestions?

Question 2: My laboratory has implemented what we think is an effective compliance program. Last year we trained over 450 employees using meetings, seminars, and lectures. The expense, in both time and money, of these activities was far too great. What can we do to save money on training but still satisfy the requirements of an effective compliance program? 

Answer: Both questions are basically asking the same thing. How does my laboratory perform compliance training in a cost-effective manner? The answer is certainly not traditional classroom education involving seminars and lectures. The cost of these methods of training is significant when you consider not only the cost of performing the training but also the hidden costs of gathering all your employees in one place at the same time and forcing your employees to leave their work stations for 1, 2, or possibly 3 hours at a time.

Classroom training is an effective method of training in some instances. If you have a limited number of employees that need training in specialized areas, this type of training might make the most sense. However, compliance training often involves getting the same basic information to a large number of people.

In order to save costs, laboratories should consider alternatives to classroom lectures. We recommend online training. The internet allows providers to train as many people as they want in a cost-effective manner. Employees can train at any time and at any pace they choose. In addition, web-based training allows for very effective documentation of all compliance training activities including course assignment, employee progress, completion dates, and test scores. Many providers use a variety of platforms, including the system developed by MCF Compliance, to perform online compliance training.

____________________________________________________________
CodeMap Compliance Tools

CodeMap offers unique publications and services to help you with all your compliance information and education needs.  For information on CodeMap Medicare Reimbursement Manuals for Laboratory, Pathology, Radiology, Nuclear Medicine and Outpatient services, please go to http://www.codemap.com/publications

For economical internet based training, go to http://www.codemap.com/training

CodeMap can provide annual compliance audits, charge-master reviews and advice on all your regulatory problems. Just give us a call at 847-381-5465.


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8/10/07: Procedure Code Modifiers
7/27/07 Billing Medicare for Peripheral Blood Smear Interpretations
7/20/07: 2008 ICD-9 Code Changes
7/13/07: New 2008 Laboratory CPT Codes
6/22/07: Excessive Charges to Medicare
6/15/07: Compliance Training
6/08/07: Glucose Testing for Hospital Patients
6/01/07: Reimbursement for Unlited Procedures
5/11/07: Molecular Diagnostic Codes and Reimbursement II
5/4/07: Molecular Diagnostic Codes and Reimbursement
04/20/2007: Medicare Coverage Vocabulary
04/13/2007: Coding Vocabulary
03/30/2007: Reimbursement Vocabulary
03/23/07: Compliance Vocabulary
3/16/07: Medically Unlikely Edits (MUE) Implementation
3/2/07: The Physician Quality Reporting Initiative (PQRI)
CodeMap Compliance Briefing: 2/23/07: New Anticoagulant Management Codes
2/09/07: Glycosylated Hemoglobin (A1c) Test Codes
02/02/2007 National Provider Identifiers
CodeMap Compliance Briefing: 1/26/07: The Deficit Reduction Act
CodeMap Compliance Briefing: 1/19/07: The Civil False Claims Act
12/19/06 Medically Unlikely Edits (MUEs)
12/11/06 - 2007 Medicare Laboratory Fee Schedule
CodeMap Compliance Briefing: 12/1/06: Category III Codes
11/17/2006 2007 Radiology CPT Codes
11/10/06 New and Revised CPT Codes for Laboratory and Pathology Procedures
11/03/06 Logical Observation Identifier Names and Codes
10/20/06 Dealing with Medicare Overpayments 
10/13/06 Stark II Issues, Part 2
10/6/06: Stark II Issues, Part 1
09/29/2006 Medical Necessity Updates
09/15/06: Medicare Coverage of PSA Testing
9/8/06 Public Consultation on Medicare Payment for Lab Tests
08/25/06: Point of Care Hemoglobin A1c Testing
08/21/06 Subscriber Questions
08/11/06 CMS Awards First A/B MAC Contract
7/21/06 Medicare Coding Vocabulary
7/14/06 Setting Reimbursement Amounts for New 2007 Codes
07/07/06: New 2007 Laboratory CPT Codes
06/09/2006 Competitive Bidding III
06/02/2006 Competitive Bidding II
05/26/2006 Competitive Bidding I
05/12/2006 Briefing: ABN Update
CodeMap Compliance Briefing: 5/5/06: Subscriber Questions
04/28/2006: Billing for Purchased Interpretations
CodeMap Compliance Briefing 4/21/06
03/31/2006: Physician Voluntary Reporting System
03/24/06 Medicare Organization/ Administration
03/17/2006: Compliance Disclosure Programs
03/10/06: Automated Test Coding and Reimbursement
02/24/2006 Pay for Performance
02/17/2006: Inherent Reasonableness
2/10/06: Microarray Codes
02/03/2006 Refresher Course: Compliance Programs
01/20/2006 Refesher Course: Medicare Reimbursement
01/13/06: Laboratory Phlebotomists in Physician Offices
CodeMap Compliance Briefing: 1/06/06 2006 Federal Budget
CodeMap Compliance Briefing: 12/16/05: Lipid Codes
CodeMap Compliance Briefing: 12/9/05: Important Year End Dates
12/02/05 Fecal Occult Blood Tests
11/18/05 Employee Compliance Training
11/04/2005 New CPT Codes for Radiology
Compliance Policy Manual
10/21/2005: New CPT Codes for Lab and Pathology
CodeMap Compliance Briefing: 10/14/05: Providing Regulatory Information to Customers
CodeMap Compliance Briefing: 10/07/05: Employee Screening
CodeMap Compliance Briefing: 9/29/05: Waived Testing
CodeMap Compliance Briefing: 09/23/05: Drafting Compliance Policies
09/16/2005 2006 Lab Codes and Proposed Payments
09/09/2005: LIS and Medical Necessity
08/19/2005: Lab Tests on the 2006 Physician Fee Schedule
08/05/2005 Coding Bone Marrow and Bone Biopsies
CodeMap Compliance Briefing 07/22/05: Coding Antibody and Antigen Assays II
07/08/2005 Coding Antibody and Antigen Assays: I
06/24/2005 Resubmitting Denied Medicare Claims
06/17/2005 Diagnosis Coding Rules-Part 2
05/20/05 Diagnosis Coding Rules Part 1
05/13/2005 Reflex Manual WBC Differentials
05/06/2005 Incident To Services
04/29/2005 CMS Manuals
04/22/2005 Reflex Testing
04/15/2005 Custom Panels
04/08/2005 Medicare Administrative Contractors (MACs)
04/01/2005 Place of Service (POS) Codes
03/18/2005 Subscriber Questions
03/11/2005 Medically Unbelieveable Edits
03/04/2005: Final Hospital Compliance Guidance 4
02/25/2005: Final Hospital Compliance Guidance 3
02/18/2005 Final Hospital Compliance Guidance 2
02/11/2005 Final Hospital Compliance Guidance
02/04/2005 Final Diabetes Screening Rules
01/28/2005 Medicare Appeals II
01/21/2005: Medicare Appeals I
01/14/2005 Providing Services to SNFs
01/07/2005 Medicare Errors
12/17/2004 Year End Subscriber Questions
12/10/2004 Coding Flow Cytometry Services
12/08/2004 Alert: 2005 CodeMap Manual Production Schedule
12/03/2004 Diabetes Screening Tests
11/22/2004 Announcing CodeMap Data Files
11/19/2004 Flow Cytometry Coding and Reimbursement
11/12/2004 New Venipuncture Rules
11/05/2004 Medicare Cardiovascular Screening Benefits
10/29/2004 Subscriber Questions
10/22/2004 Genetic Testing Modifiers
10/15/2004 Coding Glucose Tests
10/08/2004 Shared Laboratories
10/01/2004 Stark II and POLs
09/24/2004 New CPT Codes for Pathology Services
09/17/2004 New CPT Codes for Lab Services
08/27/2004 SNF Consolidated Billing Exceptions
08/20/2004 The OIG Exclusion Program
08/13/2004 Medicare Initial Preventive Physical Exam
08/06/2004 New Medicare Coverage for Screening Tests
07/30/2004 Discounts to Financially Needy Patients
07/23/2004 Date of Service for Lab Tests
07/16/2004 New CPT Codes for 2005
06/25/2004 Updates to NCDs and LMRPs
06/18/2004 New Compliance Program Guidance for Hospitals II
06/11/2004 New Compliance Program Guidance for Hospitals II
06/04/2004 Annual Physician Notices
05/21/2004 Screening Pap Smear Coverge
05/14/2004 Transfusion Medicine Codes II
05/07/2004 Transfusion Medicine Codes I
04/23/2004 Anti-Mark-Up Controversy
04/16/2004 Subscriber Questions
04/09/2004 Genetic Testing Codes II
04/02/2004 Genetic Testing Codes I
03/26/2004 Laboratory Marketing Practices III
03/19/2004 Laboratory Marketing Practices II
03/12/2004 Laboratory Marketing Practices I
03/05/2004 Medicare Payment for CLIA Waived Tests
02/27/2004 Medicare Payment for ReferredTests
02/20/2004 Grace Period for CPT Codes Eliminated
02/14/2004 CCI Edits Associated with New Lab and Pathology Codes
02/06/2004 CCI Edits Associated with New Radiology Codes
01/30/2004 Venipunctures
01/23/2004 The Medicare Prescription Drug, Improvement, and Modernization Act of 2003
01/16/2004 Travel Allowances
12/19/2003 Medicare Modernization Act
12/12/2003 Medicare Reform Bill Part 2
12/05/2003 Medicare Reform Bill Part 1
11/21/2003 New HCPCS Codes for CBCs without Platelets
11/07/2003 GA, GY and GZ Modifiers
10/31/2003 Specimen Collection
10/24/2003 Coding Qualitative Drugs-of-Abuse Tests
10/17/2003 The OIG's Work Plan, Medicare CDs, Recent Enforcement Actions.
10/10/2003 ESRD Composite Rate Lab Tests
10/03/2003 End Stage Renal Disease (ESRD) Reimbursement for Automated Tests
09/26/2003 Proposed Rules from the OIG
09/12/2003 Category III (Tracking) CPT Codes
09/05/2003 New Proposed Rules for Flow Cytometry
08/15/2003 Thyroid Testing
08/01/2003 CMS Lab Reimbursement Meeting
07/25/2003 NCD Misconceptions
07/18/2003 The -GZ Modifier
07/11/2003 Screening Mammogram Codes
06/27/2003 Correct Coding Edits II
06/20/2003 Correct Coding Edits I
06/13/2003 Diagnosis Coding Rules II
06/06/2003 Diagnosis Coding Rules I
05/23/2003 Revised Medicare Appeals Provisions II
05/16/2003 Revised Medicare Appeals Provisions I
05/09/2003 Business Associates Agreements
05/02/2003 Pathologist Interpretation of Clinical Lab Tests
04/25/2003 TC Billing of Pathology Services
04/18/2003 Medicare Reimbursement for Pathology Services
04/11/2003 How to Respond to a Search Warrant
03/28/2003 How to Respond to Subpoenas
03/21/2003 How to Respond to Investigators
03/14/2003 Mandatory Claim Submission
03/07/2003: Who Can Order Diagnostic Tests?
02/28/2003 Changes in 2003 Physician Fee Schedule
02/21/2003 Medical Necessity Requirements for Chemistry Panels, Part II
02/14/2003 Medical Necessity Requirements for Chemistry Panels I
02/07/2003: ABNs and Client Cooperation
01/31/2003: Patient Ordered and/or Performed Testing
01/24/2003: The Beneficiary Anti-Kickback Statute
01/17/2003: Significant Changes in 2003 Medicare Reimbursement
01/10/2003: 2003 Medicare Lab and Physician Fee Schedules
12/13/2002: More National Coverage Policies
12/06/2002: How Medicare Sets Fees for New CPT Codes
11/22/2002: Critical Year End Dates
11/15/2002: 2003 Medicare Laboratory Fee Schedule
11/08/2002: Stark Self-Referral Prohibitions
11/01/2002: Using Modifiers -59 and -91
10/25/2002: Introduction to Privacy Regulations
10/18/2002: New Codes for Obstetrical Ultrasound
10/11/2002: National Coverage Determinations (NCDs)
10/04/2002: Implementing a Radiology Compliance Program
09/27/2002: New 2003 Lab CPT Codes
09/20/2002: Automated Order Entry
09/13/2002: National Coverage Policy for Lipids
09/06/2002: The Anti-Kickback Statute
08/23/2002: Using the New ABN Forms
08/16/2002: Advance Beneficiary Notices
08/09/2002: Medicare Coverage for PET Scans
08/02/2002: Reflex Testing
07/26/2002: 2003 Hematology CPT Code Changes II
07/19/2002: 2003 Hematology CPT Code Changes I
07/12/2002: Direct Billing Rules II
06/28/2002: Direct Billing Rules I
06/21/2002: Medicare Reimbursement for Lipid Panels
06/14/2002: Bone Density Studies
06/07/2002: CLIA Waived Testing Rules
05/31/2002: Blood Draws and the Anti-kickback Statute
National Coverage Determination (NCD) Updates
05/01/2002 - CodeMap® Quarterly Reports, Volume I, No. 2
01/15/2002 - CodeMap® Quarterly Reports, Volume I, No. 1