CMS  Med Learn Matters SEO516
Release Date: April 22, 2005

Revision to the Centers for Medicare & Medicaid Services (CMS) prior directive: On April 22, 2005 claims that fail the matching edits will not be denied, but will be determined unprocessable and returned to the provider.

In October 2004, CMS made a software change to require an exact match on beneficiary First Initial, Surname, and Health Insurance Claim Number submitted on the claim. Since this change was implemented the number of unprocessable claims because of name/number mismatch tripled. To resolve these unprocessed claims, providers should bill using the name and number as it appears on the beneficiary Medicare card.

CMS  Federal Register: 45 CFR Part 162
Publication Date: January 23, 2004
Effective Date: May 23, 2005

CMS announced the implementation of enumeration for the National Provider Identifier (NPI). The NPI is the standard unique health identifier for health care providers that was adopted by the Secretary of Health and Human Services under the Health Insurance Portability and Accountability Act of 1996. CMS’s announcement letter informs health care providers about the NPI, describes three ways to obtain an NPI, and gives them guidance as to what they should do once they have obtained their NPI.

Additional resources: NPI  Dear Provider letter

CMS  Transmittal 534
Publication Date: April 29, 2005
Effective Date: July 01, 2005

CMS has released the July 2005 update to its Medicare National Coverage Determinations (NCDs) Manual for Clinical Diagnostic Laboratory Services. This update revises a number of the lab NCDs include:

• Thyroid Testing: 84436, 84439, 84443, 84479 added ICD-9 code 733.02
• Tumor Antigen by Immunoassay CA 19-9: 86301 added ICD-9 codes 156.0 and 156.2
• Hepatitis Panel: 80074 deleted ICD-9 code 784.69
• Tumor Antigen by Immunoassay CA 125: 86304 added ICD-9 Code 789.39
• Blood Counts: 85004,85007,85008,85013,85014,85018,85025,85027,85032,85048,85049 added ICD-9 codes V77.1, V81.0, V81.1 and V81.2

CMS

At the April 25, 2005 Lab Open Door Forum CMS noted that the following guidance in the current National Correct Coding Policy Manual, Chap. 10, Pathology/Laboratory Services essentially prohibits billing for a reflexed manual WBC differential performed as a result of an abnormal or flagged automated WBC differential.

"If, after a test is ordered and performed, additional related procedures are necessary to provide or confirm the result, these would be considered part of the ordered test. For example, if a patient with leukemia has a thrombocytopenia, and a manual platelet count (CPT 85032) is performed in addition to the performance of an automated hemogram with automated platelet count (85027), it would be inappropriate to report codes 85032 and 85027 because the former provides a confirmatory test for the automated hemogram and platelet count (85027). As another example, if a patient has an abnormal test result and repeat performance of the test is done to verify the result, the test is reported as one unit of service rather than two."

Based on this new guidance, a CBC and manual WBC differential may only be billed together when a physician specifically orders a CBC without automated WBC differential (85027) and a manual WBC differential (85007). In this case, CPT code 85027 and 85007 would be reimbursed. CCI edits prohibit the combination of 85007 and 85025 (CBC with automated WBC differential) based on the fact that the manual WBC duplicates the automated WBC differential included in 85025.

Reference:  American Society for Clinical Laboratory Science - South Dakota

CMS  MM3785
Publication Date: May 06, 2005
Effective Date: January 01, 2005

Part B travel allowance for 2005 is increased to $0.855 per mile (HCPCS code P9603) and $8.55 per flat rate trip basis (P9604), under a correction announced by Medicare and retroactive to January 01.

Medicare contractors aren't required to adjust travel fees already paid, but must do so for claims that clinical laboratories bring to their attention.

The fee increase results from an increase in the federal standard mileage rate, which is one portion of the travel allowance formula. The previously announced rate for this year was $0.385 per mile; now, it's $0.405. The personnel portion of the formula remains unchanged at $0.45 per mile.

Additional reference:  CR 3785

California – Medicare: NHIC
Effective Date: June 27, 2005

NHIC will implement the new draft LCD for 86003 Allergen Specific IGE; Quantitative or OR Semiquantiative, each allergen and 86005 Allergen Specific IGE; Qualitative, Multiallergen Screen (dipstick, paddle or disk).

The policy is available at the following link:  L9269

California – Medi-Cal
Effective Date: May 01, 2005

Medi-Cal has issued a claim submission reminder to providers submitting for Children's Treatment Program (CTP).

The claim must include a valid recipient identification number, Benefits Identification Card (BIC) and Client Identification Number or Social Security Number.

The PM 160 form must be attached.

The policy is available at the following link:   Children's Treatment Program

California – Medi-Cal
Effective Date: June 01, 2005

Providers possessing a Clinical Laboratory Improvement Amendments (CLIA) Certificate of Wavier or Provider - Performed Microscopy Procedures (PPMP) must utilize a test kit and bill the program utilizing a QW modifier with for the following codes: 80061, 80101, 81003, 81007,82010, 82044, 82055, 82120, 82273, 82274, 82465, 82523, 82570, 82679, 82947, 82950, 82951, 82952, 82985, 83001, 83002, 83036, 83518, 83605, 83718, 83986, 84460, 84478, 84703, 85014, 85018, 85610, 86294, 86308, 86318, 86618, 86701, 87077, 87210, 87449, 87804, and 87880.

Providers who possess a CLIA Certification of Accreditation or CLIA Certificate of Compliance are not required to utilize a test kit when performing the following test: 80061, 80101, 81003, 81007,82010, 82044, 82055, 82120, 82273, 82274, 82465, 82523, 82570, 82679, 82947, 82950, 82951, 82952, 82985, 83001, 83002, 83036, 83518, 83605, 83718, 83986, 84460, 84478, 84703, 85014, 85018, 85610, 86294, 86308, 86318, 86618, 86701, 87077, 87210, 87449, 87804, and 87880. However if a test kit is utilize, the provider must be certified in the appropriate proficiency testing specialty or sub-specialty.

A QW is not required for the following CPT-4 Codes 81002, 81025, 82270, 82962, 83026, 84830, 85013 and 85651 in order for the test to be classified as waived. CPT-4 Code 89300 is identified as a waived test by CMS but it is not a benefit of the Medi-Cal Program.

Reference:  Medi-Cal Publications