XIFIN is pleased to announce the addition of a Travel Fee Calculator to its Lab Resources.

In 1998 HCFA altered submission guidelines and reimbursement criteria for travel allowance. Labs may bill a pro-rated flat fee for total miles traveled when mileage is less than 20; and a pro-rated flat fee or a per mile fee when the total mileage is greater than 20.

To assist labs in determining which option best maximizes reimbursable travel fees, XIFIN makes a calculator available on our website for your use and reference.

XIFIN Lab Resources Travel Fee Calculator.

CMS

Medlearn Matters MM3995
Publication Date: August 26, 2005
Effective Date: October 01, 2005

Quarterly Update to Correct Coding Initiative (CCI) edits

The next update of CCI edits will be effective on October 01, 2005. CCI edits and Mutually Exclusive Code (MEC) edits are available on the CMS web site. The web site will be updated with the Version 11.3 edits as soon as they are effective.

CMS

Transmittal 643 CR 3897
Publication Date: August 12, 2005
Effective Date: January 01, 2005
Implementation Date: November 14, 2005

Carrier Manual Update to Assignment on Carrier Claims

In “mandatory assignment” situations, i.e., where payment under the Act can be made only on an assignment-related basis to the supplier, the beneficiary (or the person authorized to request payment on the beneficiary’s behalf) is not required to assign the claim to the supplier in order for an assignment to be effective. However, the beneficiary (or the person authorized to request payment on the beneficiary’s behalf) must continue to authorize the release of medical or other information necessary to process the claim and request payment of Medicare benefits for the Medicare Part B covered services pursuant to 42 C.F.R 424.32 and 424.36 (see also Pub. 100-04, ch. 1, sect. 50.1). Physicians or suppliers who agree to (or must by law) accept assignment from Medicare cannot attempt to collect more than the appropriate Medicare deductible and coinsurance amounts from the beneficiary, his/her other insurance, or anyone else.

CMS

Medlearn Matters MM3946
Publication Date: October 29, 2004
Effective Date: January 01, 2006

Update to Medicare's Duplicate Claims Edit for Clinical Diagnostic Services in the Common Working File (CWF)

The Centers for Medicare & Medicaid Services (CMS) issued CR 3551, Transmittal 124, on October 29, 2004, to implement a new edit in Medicare’s systems, effective April 01, 2005, to check for duplicate claims for referred clinical diagnostic laboratory services and purchased diagnostic services submitted by physicians/supplier to more than one carrier.

This edit for clinical diagnostic laboratory services and purchased diagnostic claims, which was implemented on April 04, 2005, did not edit line items that contained the “90” modifier.

When performing the data matching, the Medicare duplicate claim edit for referred clinical diagnostic laboratory performed the matching on the claim fields: (a) Beneficiary Name; (b) Beneficiary Health Insurance Claim Number (HICN); (c) Current Procedural Terminology (CPT)/Healthcare Common Procedure Coding System (HCPCS) code; (d) Date of Service; and (e) CPT/HCPCS Code Modifier. That edit was not applied to claims with a “90” modifier. Medicare will modify the duplicate claim edit to reject all clinical laboratory services submitted to carriers when it has been determined that another carrier has already paid for the same service on the same date of service, with the exception of those claims containing the “91” modifier. This modified edit will apply to all laboratory claims with dates of service on or after January 01, 2006. When claims are denied as a result of this edit, Medicare carriers will use remark code N347 on the remittance advice to show “Your claim for a referred or purchased service cannot be paid because payment has already been made for this same service to another provider by a payment contractor representing the payer.”

Note: Repeat clinical laboratory services for the same beneficiary on the same date of service are identified by the “91” modifier. When performing the data matching, the CWF duplicate claim edit for referred clinical diagnostic laboratory service will not include the “91” modifier on referred laboratory claims in the matching criteria, but will perform matching on all others as specified above.

CMS

Medlearn Matters CR 3984
Publication Date: August 05, 2005 (revised)
Effective Date: October 01, 2005
Implementation Date: October 03, 2005

The following tests are approved by the FDA as waived tests under the CLIA.

Note: The tests mentioned on the first page of the Attachment included with CR3984 (i.e., CPT codes: 81002, 81025, 82270, G0107, 82962, 83026, 84830, 85013, and 85651) do not require a QW modifier to be recognized as a waived test.

CMS

Medlearn Matters MM3890
Effective Date: January 01, 2006
Implementation Date: January 01, 2006

The ESRD 50/50 rule requires the billing laboratory to determine (for the same beneficiary on the same date-of-service):

• The number of AMCC tests (ordered and performed) that are included in the composite payment rate paid to the ESRD facility (or the monthly capitation payment made to the furnishing physician); and
• The number of covered non-composite tests paid.

The proportion of composite versus non-composite tests calculated by the billing laboratory is then used to determine whether separate payment may be made for all tests performed on that day.

Effective January 1, 2006, when billing for AMCC tests for an ESRD patient, the laboratory must identify the appropriate modifier for each test, as follows:

• Modifier “CD” – AMCC test has been ordered by an ESRD facility (or MCP physician) that is part of the composite rate and is not separately billable.
• Modifier “CE” – AMCC test has been ordered by an ESRD facility (or MCP physician) that is a composite rate test but is beyond the normal frequency covered under the rate and is separately reimbursable based on medical necessity.
• Modifier “CF” – AMCC test has been ordered by an ESRD facility (or MCP physician) that is not part of the composite rate and is separately billable.

CMS

Medlearn Matters CR 4005
Publication Date: August 19, 2005
Effective Date: October 01, 2005
Implementation Date: October 03, 2005

CR4005 announces changes to the list of codes included in the October 2005 release of the Medicare Laboratory National Coverage Determination (NCD) edit module for clinical diagnostic laboratory services. These changes are a result of new ICD-9-CM code changes that become effective October 01, 2005.

Urine Culture
In accordance with the coding analysis, CMS is adding new ICD-9-CM code
585.6, End Stage Renal Disease, to the list of ICD-9-CM Codes Covered by Medicare for Urine Culture. CMS is deleting ICD-9-CM code 585, Chronic Renal Failure, from the same list for this NCD.

Immunodeficiency Virus (HIV) Testing (Diagnosis)
CMS is adding new ICD-9-CM codes to the list of ICD-9-CM Codes Covered by Medicare for Human Immunodeficiency Virus (HIV) Testing (Diagnosis). Those codes are as follows:
287.30 - Primary thrombocytopenia, unspecified
287.31 - Immune thrombocytopenic purpura
287.32 - Evans’ syndrome
287.33 - Congenital and hereditary thrombocytopenic purpura
287.39 - Other primary thrombocytopenia
CMS is deleting ICD-9-CM code 287.3, Primary Thrombocytopenia, from the same list for this NCD.

Blood Counts
CMS is adding new ICD-9-CM codes to the list of ICD-9-CM Codes That Do Not Support Medical Necessity for Medicare for Blood Counts. Those codes are as follows:
443.82 - Erythromelalgia V26.31 - Testing for genetic disease carrier status
525.40 - Complete edentulism, unspecified
525.41 - Complete edentulism, class I
525.42 - Complete edentulism, class II
525.43 - Complete edentulism, class III
525.44 - Complete edentulism, class IV
525.50 - Partial edentulism, unspecified
525.51 - Partial edentulism, class I
525.52 - Partial edentulism, class II
525.53 - Partial edentulism, class III
525.54 - Partial edentulism, class IV
V26.32 - Other genetic testing
V26.33 - Genetic counseling
V49.84 - Bed confinement status
V59.70 - Egg (oocyte) (ovum) donor, unspecified
V59.71 - Egg (oocyte) (ovum) donor, under age 35,anonymous recipient
V59.72 - Egg (oocyte) (ovum) donor, under age 35,designated recipient
V59.73 - Egg (oocyte) (ovum) donor, age 35 and over,anonymous recipient
V59.74 - Egg (oocyte) (ovum) donor, age 35 and over,designated recipient
V62.84 - Suicidal ideation
CMS is deleting ICD-9-CM code V26.3, Genetic Counseling and Testing, from the same list for this NCD.

Partial Thromboplastin Time (PTT)
CMS is adding new ICD-9-CM codes to the list of ICD-9-CM Codes Covered by Medicare for Partial Thromboplastin Time (PTT). Those codes are as follows:
287.30 - Primary thrombocytopenia, unspecified
287.31 - Immune thrombocytopenic purpura
287.32 - Evans’ syndrome
287.33 - Congenital and hereditary thrombocytopenic purpura
287.39 - Other primary thrombocytopenia
585.4 - Chronic kidney disease, Stage IV (severe)
585.5 - Chronic kidney disease, Stage V
585.6 - End stage renal disease
585.9 - Chronic kidney disease, unspecified
CMS is deleting ICD-9-CM codes, 287.3, Primary Thrombocytopenia, and 585, Chronic Renal Failure, from the same list for this NCD.

Prothrombin Time (PT)
CMS is adding new ICD-9-CM codes to the list of ICD-9-CM Codes Covered by Medicare for Prothrombin Time (PT). Those codes are as follows:
287.30 - 287.39 as defined in the section on Partial Thromboplastin Time (PTT) above
443.82 Erythromelalgia
585.4 - 585.9 as defined in the section on Partial Thromboplastin Time (PTT) above
CMS is deleting ICD-9-CM code, 287.3, Primary Thrombocytopenia, and 585, Chronic Renal Failure, from the same list for this NCD.

Serum Iron Studies
CMS is adding new ICD-9-CM codes to the list of ICD-9-CM Codes Covered by Medicare for Serum Iron Studies. Those codes are as follows:
287.30 - 287.39 as defined in the section on Partial Thromboplastin Time (PTT) above
585.4 - 585.9 as defined in the section on Partial Thromboplastin Time (PTT) above
CMS is deleting ICD-9-CM codes 287.3, Primary Thrombocytopenia, and 585, Chronic Renal Failure, from the same list for this NCD.

Blood Glucose Testing
CMS is adding new ICD-9-CM codes to the list of ICD-9-CM Codes Covered by Medicare for Blood Glucose Testing. Those codes as follows:
276.50 - Volume depletion, unspecified
276.51 - Dehydration
276.52 - Hypovolemia
CMS is deleting ICD-9-CM code 276.5, Volume Depletion, from the same list for this NCD.

Thyroid Testing
CMS is adding new ICD-9-CM codes to the list of ICD-9-CM Codes Covered by Medicare for Thyroid Testing. Those codes are as follows:
327.00 - Organic insomnia, unspecified
327.01 - Insomnia due to medical condition classified elsewhere
327.09 - Other organic insomnia
327.29 - Other organic sleep apnea
327.52 - Sleep related leg cramp
327.8 - Other organic sleep disorders

Lipid Testing
CMS is adding new ICD-9-CM codes to the list of ICD-9-CM Codes Covered by Medicare for Lipid Testing. Those codes are as follows:
278.02 - Overweight
585.4 - 585.9 as defined in Partial Thromboplastin Time (PTT) above
CMS is deleting ICD-9-CM code 585, Chronic Renal Failure, from the same list for this NCD.

Digoxin Therapeutic Drug Assay
CMS is adding new ICD-9-CM codes to the list of ICD-9-CM Codes Covered by Medicare for Digoxin Therapeutic Drug Assay. Those codes are as follows:
276.50 - Volume depletion, unspecified
276.51 - Dehydration
276.52 - Hypovolemia
426.82 - Long QT syndrome
585.1 - Chronic kidney disease, Stage I
585.2 - Chronic kidney disease, Stage II (mild)
585.3 - Chronic kidney disease, Stage III (moderate)
585.4 - Chronic kidney disease, Stage IV (severe)
585.5 - Chronic kidney disease, Stage V
585.6 - End stage renal disease
585.9 - Chronic kidney disease, unspecified
CMS is deleting ICD-9-CM codes 276.5, Volume Depletion, and 585, Chronic Renal Failure, from the same list for this NCD.

Prostate Specific Antigen Testing
CMS is adding new ICD-9-CM codes to the list of ICD-9-CM Codes Covered by Medicare for Prostate Specific Antigen Testing. Those codes are as follows:
599.60 - Urinary obstruction, unspecified
599.69 - Urinary obstruction, not elsewhere classified
CMS is deleting ICD-9-CM codes, 599.6, Urinary Obstruction, from the same list for this NCD.

Gamma Glutamyl Transferase Testing
CMS is adding new ICD-9-CM codes to the list of ICD-9-CM Codes Covered by Medicare for Gamma Glutamyl Transferase Testing. Those codes are as follows:
291.82 - Alcohol induced sleep disorders
567.21 - Peritonitis (acute) generalized
567.22 - Peritoneal abscess
567.23 - Spontaneous bacterial peritonitis
567.29 - Other suppurative peritonitis
567.38 - Other retroperitoneal abscess
567.39 - Other retroperitoneal infections
567.81 - Choleperitonitis
567.82 - Sclerosing mesenteritis
567.89 - Other specified peritonitis
585.6 - End Stage Renal Disease
CMS is deleting ICD-9-CM codes, 567.2, Suppurat Peritonitis, 567.8, Peritonitis NEC and 585, Chronic Renal Failure, from the same list for this NCD.

Fecal Occult Blood Testing
CMS is adding ICD-9-CM codes
287.30 - 287.39 (as defined in Partial Thromboplastin Time (PTT) above) to the list of ICD-9-CM Codes Covered by Medicare for Fecal Occult Blood Testing. CMS is deleting ICD-9- CM code, 287.3, Primary Thrombocytopenia, from the same list for this NCD.

Negotiated Laboratory NCDs
In accordance with the coding analysis, CMS is adding new ICD-9-CM codes to the list of ICD-9-CM Codes Not Covered by Medicare for the Negotiated Laboratory NCDs. Those codes are as follows:
V17.81 - Family history, Osteoporosis
V17.89 - Family history, Other musculoskeletal diseases
V18.9 - Family history, Genetic disease carrier
CMS is deleting ICD-9-CM code, V17.8, Family history of certain chronic disabling diseases, from the same list.

CMS

CMS Manual System CR4031
Publication Date: August 26, 2005
Effective Date: January 01, 2005

CR4031 amends payment files issued to Medicare carriers and intermediaries based upon the November 15, 2004, Final Rules for the 2005 Medicare Physician Fee Schedule Database.

The changes to the fee schedule involve numerous CPT/HCPCS codes. While many of these changes are effective retroactive to January 1, 2005, please note that your carrier/FI will not reprocess claims already processed, unless you request them to do so.

The complete details of these changes to the October update to the 2005 Medicare Fee Schedule Database are described in an attachment to CR 4031, which is the official instruction issued to your carrier/intermediary. That instruction may be viewed by selecting the link above for the CMS web site.