Laboratory Medicare & Medicaid Compliance

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CaroMont Regional Medical Center Laboratory is dedicated to providing excellent service while complying with all laws and regulations pertaining to the delivery of and billing for services to federal and state government programs such as Medicare and Medicaid.

In an ongoing effort to ensure compliance with Centers for Medicare and Medicaid Services (CMS), CRMC Laboratory has developed specific policies and procedures for the prevention of processes or practices that may result in billing errors or be viewed as fraudulent or abusive.

It is our goal, to ensure that referring physicians and clients are informed of our policies.  Your awareness and understanding of these policies will assist us in providing efficient, quality patient care while meeting our responsibilities as a provider of laboratory services.

Medical Necessity
Medicare is required by federal law to pay only for services it considers medically necessary to diagnose or treat an illness or injury or to improve the function of a malformed body member.  As a result, Medicare often requires a specific diagnosis for certain laboratory tests before they will consider a test medically necessary.

Although physicians may order any tests they feel are necessary to diagnose and treat a patient appropriately, Medicare will only pay for those that meet the Medicare definition of medical necessity.

Therefore, all Medicare claims submitted by CaroMont Regional Medical Center must include complete medical necessity documentation using the ICD-9CM coding system to be compliant and eligible for reimbursement of services provided.

Physician and Client Responsibilities
It is the responsibility of the ordering physician and laboratory client to submit all clinically relevant ICD-9 codes for each test on the laboratory requisition at the time of the test order.

Patients presenting to CRMC outpatient collection centers with laboratory orders from their physician which lack medical necessity documentation for tests ordered may experience a delay in services, or will be asked to sign an Advance Beneficiary Notice (ABN) accepting financial responsibility for those tests which Medicare is likely to deny payment.  Therefore, it is important that the laboratory requisition or physician order provides complete medical necessity documentation.

For specimens submitted to our Outreach Services department, the laboratory requisition accompanying the specimen should include all medical necessity documentation.

If medical necessity documentation is not submitted with the requisition or a valid ABN was not obtained, the charges for these services will be billed to the referring physician or client office.

Important Points to Remember:

  • ICD-9 diagnosis codes are the only acceptable form of medical necessity documentation.
  • Narrative diagnoses are not acceptable.
  • ICD-9 code(s) submitted must be consistent with documentation in the patient’s record.
  • When choosing an ICD-9 code, always select the code that most accurately describes the patient’s condition and code to the highest level of specificity.
  • Only physician office or client staff authorized and experienced with coding should  provide ICD-9 codes for laboratory services.
  • Providing ICD-9 codes on the Laboratory Requisition will avoid unnecessary phone calls to physician and client offices as well as delays in service to patients to obtain  medical necessity documentation.
  • An ABN form must be submitted with each lab requisition when a limited coverage test is ordered without an ICD-9 code that supports the medical necessity of the test.
  • Laboratory services provided through our Outreach Services department without medical necessity documentation or a valid ABN will be billed to the referring physician or client office.

Limited Coverage Tests
Medicare and local Medicare intermediary- Palmetto GBA, have established national or local medical review policies for specific laboratory tests.  These policies include a list of diagnosis codes to indicate what clinical circumstances justify medical necessity of an individual test.  In addition, these policies also contain such information as specific non-covered diagnosis codes, coding guidelines, reason for denial, and frequency limitations which may apply.

Click here to view limited coverage tests and Medicare approved ICD-9 diagnosis codes.

To view a coverage policy in its entirety, click on link and follow instructions.

  1. Visit http://www.palmettogba.com/medicare
  2. View AMA License, Click Accept
  3. Select J11 Part A MAC – NC, SC, VA,WV
  4. Click Medical Policies
  5. Select LCDs and NCDs

CRMC Laboratory discourages the use of any lists, “cheat sheets”, or software containing commonly used ICD-9 codes by physician or client offices, especially for the purpose of ensuring coverage and reimbursement.

Routine Screening Tests:
Routine screening test(s) are not a Medicare covered service unless specified in Medicare law.   The patient will be financially responsible for payment of routine screening tests.

Medicare Preventive Services Quick Reference Chart
https://www.cms.gov/Medicare/Prevention/PrevntionGenInfo/Downloads/MPS_QuickReferenceChart_1.pdf

Advance Beneficiary Notice (ABN)
The intent and purpose of an ABN is to notify Medicare beneficiaries, in writing, that a test being ordered for them by their physician may not be paid for by Medicare.   The beneficiary has the opportunity to make an informed decision about whether or not to have the test and be financially responsible should Medicare deny payment.

Medicare allows CaroMont Regional Medical Center to bill the patient for a denied test only if an ABN is completed and signed by the patient prior to specimen collection.

Routine or blanket ABNs are prohibited by Medicare where there is no reasonable expectation of non-coverage.

An ABN should be obtained when one or more of the following circumstances exist:

  • The diagnosis does not meet medical necessity guidelines.
  • The test(s) is for a routine exam or screening.
  • The test(s) is for experimental or investigational use.
  • The number of times the test(s) can be ordered within a certain time period is limited by Medicare.
  • The test(s) has not been approved by the Food and Drug Administration.
  • No diagnosis provided.

The ABN is not valid unless the following information is provided or completed:

  • Patient name and Medicare number
  • Description or test(s) that may be denied
  • Reason why service may be denied
  • Estimated test(s) cost – Contact Laboratory Client Services
  • Explanation to patient
  • Patient reads and checks Option Box
  • Patient signature and date
  • Provide patient a copy of completed and signed ABN for their records.

ABN Forms

Additional ABN forms are available upon request from client services:  (704) 834-2881

Clinical Consultants
CRMC Laboratory has clinical consultants available to answer questions regarding appropriate testing and medical necessity.

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