CMS

Changes to Independent Laboratory Billing for the Technical Component
of Physician Pathology Services

Transmittal: R1148CP (PDF).
Effective Date: January 1, 2007
Implementation Date: February 5, 2007

Independent laboratories which qualify to bill under the Tax Relief and Health Care Act of 2006 (Section 104) may continue to bill their carrier or A/B MAC for the Technical Component (TC) of physician pathology services furnished to patients of a covered hospital, regardless of the beneficiary's hospitalization status (inpatient or outpatient) on the date that the service was performed, through calendar year 2007.

  CMS

The next update of CCI edits will be effective on January 01, 2007. CCI edits and Mutually Exclusive Code (MEC) edits are available on the CMS web site. The web site will be updated with the Version 13.0 edits as soon as they are effective.

There are NO Modified, CP Pairs

There are NO Deleted, CP Pairs

New Mutually Exclusive Pairs

There are NO Modified, ME Pairs

There are NO Deleted, ME Pairs

  CMS

CMS released CR 5359 which applies to the implementation of the first Competitive Bidding Area (CBA1).

During the first quarter of 2007 CMS will provide Medicare contractors with:

• A national zip code pricing file which will identify the zip codes included in the first CBA.
• A list of laboratories eligible to participate in the first CBA, including winning and passive laboratories; and
• A list of laboratories that are not selected to participate in the CBA1.

Laboratory services covered in the demonstration in CBA1 with dates of service between April 01, 2007 and March 31, 2010, will be paid according to the competitive bidding demonstration fee schedule amounts for laboratory services on that schedule. If a service is not included in the demonstration schedule, it will be paid based on the clinical laboratory fee schedule.

Medicare will reject any claim within the date range listed above which includes Modifier 90 for demonstration covered services provided to beneficiaries residing in the CBA, regardless of the referring laboratory’s participation status.

Claims for non-winning laboratories with dates of service between April 1, 2007 and March 31, 2010 will be denied. Non-winning laboratories will not be allowed to transfer payment responsibility to Medicare patients with an ABN.

Line items for demonstration services and non-demonstration services may be submitted on one claim.

Laboratories providing clinical laboratory services to only Medicare beneficiaries with End Stage Renal Disease (ESRD) residing in the CBA will not be required to bid in the demonstration. These laboratories will be considered “Passive-ESRD laboratories”. Passive ESRD labs will be paid based on the competitive bidding demonstration fee schedule for demonstration tests provided to ESRD patients residing in a CBA. ESRD labs who expand their business to provide clinical laboratory services for non-ESRD beneficiaries residing in the CBA will be terminated from the competitive bidding demonstration.

The Change Request can be viewed at the following link: R50Demo (PDF).

For instructions on phase one of the laboratory competitive bidding project, view the following web site: R49Demo (PDF).

  CMS

Transmittal:  R1122CP (PDF).

Pathology services on the Physician fee schedule will not change in 2007, subsequent to Congress blocking the proposed 5% cut. The Medicare Part B fee schedule for 2007 provides a zero update.

Travel allowance to collect a specimen from a nursing home or homebound patient will also remain at the 2006 rates in 2007. For dates of service January 01, 2007 through December 2007, the fee for clinical laboratory travel code P9603 is $0.935 per mile and for code P9604 is $9.35 per flat rate trip basis.

Rates have been set for 11 new codes announced for 2007 through the cross walk process as follows:

You can access to the 2007 clinical laboratory fee schedule data file is available at:  http://www.cms.hhs.gov/ClinicalLabFeeSched on the CMS web site.

  CMS

Transmittal:  R178PI.
Effective Date: January 01, 2007

In order to lower the Medicare paid claims error rate, CMS established units of service edits referred to as MUEs. The National Correct Coding Initiative (NCCI) contractor develops and maintains MUEs.

• An MUE is defined as an edit that tests claim lines for the same beneficiary, HCPCS code, date of service, and billing provider against a criteria number of units of service.
• The MUEs will auto-deny claim line items containing units of service billed in excess of the MUE criteria or Return to Provider (RTP) claims that contain lines that have units of service that exceed an MUE criteria.
• MUEs that will be implemented by this notice are based on anatomic considerations. CMS will allow an appeals process for those claim line items that are denied as a result of an MUE edit.
• An appeals process will not be allowed or required for claims that are RTP’ed. Providers should resubmit corrected claims.
• This set of MUEs based on anatomical considerations addresses approximately 2,800 codes. Affected clinical lab services are Pap smear screening - G0123, G0124, G0143, G0144, G0145 - whose MUEs are set at one.
• Excess charges due to units of service greater than the MUE may not be billed to the beneficiary or subject to an ABN.

See also Medicare Matters: MM5402.

  CMS

Transmittal:  1115 (PDF).

For 2007, the new CPT/HCPCS code 87808QW (Infectious agent antigen detection by immunoassay with direct optical observation; Trichomonas vaginalis) replaces the code 87899QW that was assigned to the Genzyme OSOM Trichomonas Rapid Test.

  NHIC

ICD-9 Codes that Support Medical Necessity for Allergy Testing L19094

   ICD-9-CM codes 478.1 and 995.1 are effective prior to 10/1/2006.

*XIFIN note: revision history explanation references 995.2 deleted rather than 995.1 as stated

Effective January 1, 2007 the following list of ICD-9-CM Codes will be covered for CPT Code 86003

  California — Medi–cal

Effective for dates of service on or after January 01, 2007, the California Department of Health Services (CDHS) is updating the maximum reimbursement amounts for laboratory chemistry procedures. These rates are as follows:

To comply with Welfare and Institutions Code, Section 14105.22, the Medi-Cal maximum reimbursement rates for clinical laboratory or laboratory procedures must be no higher than 80 percent of the average of the Medicare rates allowed by National Heritage Insurance Company (NHIC)-North and NHIC-South.

Information about individual laboratory procedure reimbursement rates for the CPT-4 code 80000 series and HCPCS codes S3620 and S3820 can be found on the Medi-Cal Web site (www.medi-cal.ca.gov) by clicking “Medi-Cal Rates” under the “Provider Reference” heading.

  California — Medi–cal

Effective for dates of service on or after January 01, 2007, CPT-4 code 82607 [vitamin B-12]) is reimbursable only when billed in conjunction with one or more of the following ICD-9 codes. Reimbursement continues to be restricted to three tests per year for the same recipient by the same provider, unless medical justification is entered in the Remarks area/Reserved for Local Use field (Box 19) of the claim or submitted as an attachment.

This information is reflected on manual replacement page path chem 3 and 4 (Part 2).