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MLN Matters: MM6045 |
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Effective Date: July 1, 2008 |
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Implementation Date: |
The current update reflects the following changes:
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Column 1 |
Column 2 |
Effective Date |
Policy |
Mods |
Effective Date |
Policy |
Mods |
|
89310 |
89321 |
4/01/2002 |
More Extensive Procedure |
0 |
4/01/2002 |
More Extensive Procedure |
1 |
|
89320 |
89300 |
1/01/1996 |
HCPCS/CPT procedure code definition |
0 |
1/01/1996 |
HCPCS/CPT procedure code definition |
1 |
|
89320 |
89310 |
1/01/1996 |
HCPCS/CPT procedure code definition |
0 |
1/01/1996 |
HCPCS/CPT procedure code definition |
1 |
|
89320 |
89321 |
4/01/2002 |
More Extensive Procedure |
0 |
4/01/2002 |
More Extensive Procedure |
1 |
|
82270 |
82272 |
1/01/1996 |
More Extensive Procedure |
0 |
1/01/1996 |
More Extensive Procedure |
1 |
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Column 1 |
Column 2 |
Effective Date |
Policy |
Mods |
|
0124T |
0186T |
7/01/2008 |
Mutually Exclusive Procedures |
1 |
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New CLIA Waived Tests | ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
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CMS The latest CLIA waived tests approved by the FDA.
Table 1 - FDA Approved Waived Tests under CLIA
CMS has added 24 new CLIA waived tests.
The following table includes the latest new tests approved by the Food and Drug Administration as waived tests under CLIA.
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Date of Service (DOS) for Clinical Laboratory and Pathology Specimens
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MLN Matters: MM6018 |
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Effective Date: January 1, 2009 |
General Rule: The DOS of the test/service must be the date the specimen was collected.
Clinical Laboratory Fee Schedule - Medicare Travel Allowance Fees for Collection of Specimens
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MLN Matters: MM5996 |
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Effective Date: January 1, 2008 |
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Implementation Date: June 30, 2008 |
As of January 1, 2008 t he per flat rate trip basis travel allowance (P9604) is $9.55, and the per mile travel allowance (P9603) is $0.955 cents per mile.
Note that Medicare contractors will not re-process claims that were processed before the new rates were implemented unless you bring such claims to their attention.
Changes to the Laboratory National Coverage Determination (NCD) Edit Software for July 2008
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MLN Matters: MM6084 |
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Effective Date: July 1, 2008 |
Add ICD-9-CM codes 079.83 and 288.66 to the list of ICD-9-CM codes covered by Medicare for the HIV Testing (190.14) NCD.
Modify the descriptor for Current Procedural Terminology (CPT( code 86701 in the HIV Testing (190.14) NCD to read “Antibody; HIV-1.”
Modify the descriptor for CPT code 86702 in the HIV Testing (190.14) NCD to read “Antibody; HIV-2.”
Modify the descriptor for CPT code 86703 in the HIV Testing (190.14) NCD to read “Antibody; HIV-1 and HIV-2, single assay.”
Add ICD-9-CM codes 388.45, 389.05, 389.06, 389.13, 389.17, 389.20, 389.21, 389.22, V25.04, V26.41, V26.49, V26.81, V26.89, V49.85 and V72. 12 to the list of ICD-9-CM codes that Do Not Support Medical Necessity for the Blood Counts (190.15) NCD.
Delete ICD-9-CM codes 389.2, V26.4 and V26.8 from the list of ICD-9-CM codes that Do Not Support Medical Necessity for the Blood Counts (190.15) NCD.
Modify the descriptor for ICD-9-CM code 389.14 to read “Central hearing loss” in the list of ICD-9-CM codes that Do Not Support Medical Necessity for the Blood Counts (190.15) NCD;
Modify the descriptor for ICD-9-CM code 389.18 to read “Sensorineural hearing loss, bilateral” in the list of ICD-9-CM codes that Do Not Support Medical Necessity for the Blood Counts (190.15) NCD; and Modify the descriptor for ICD-9-CM code 389.7 to read “Deaf, non-speaking, not elsewhere classifiable” from the list of ICD-9-CM codes that Do Not Support Medical Necessity for the Blood Counts (190.15) NCD.
Add ICD-9-CM codes 415.12, 789.51, 789.59, V12.53, and V12.54 to the list of ICD-9-CM codes covered by Medicare for the Prothrombin Time (190.17) NCD.
Delete ICD-9-CM code 789.5 from the list of ICD-9-CM codes covered by Medicare for the Prothrombin Time (190.17) NCD.
Add ICD-9-CM codes 233.30, 233.31, 233.32, and 233.39 to the list of ICD-9-CM codes covered by Medicare for the Serum Iron Studies (190.18) NCD.
Delete ICD-9-CM code 233.3 from the list of ICD-9-CM codes covered by Medicare for the Serum Iron Studies (190.18) NCD.
Add ICD-9-CM codes 258.01, 258.02 and 258.03 to the list of ICD-9-CM codes covered by Medicare for the Glycated Hemoglobin/Glycated Protein (190.21) NCD.
Delete ICD-9-CM code 258.0 from the list of ICD-9-CM codes covered by Medicare for Glycated Hemoglobin/Glycated Protein (190.21) NCD.
Add ICD-9-CM codes 255.41, 255.42, 258.01, 258.02, 258.03, 787.20, 787.21, 787.22, 787.23, 787.24, 787.29, 789.51 and 789.59 to the list of ICD-9-CM codes covered by Medicare for the Thyroid Testing (190.22) NCD.
Delete ICD-9-CM codes 255.4, 258.0, 787.2 and 789.5 from the list of ICD-9-CM codes covered by Medicare for the Thyroid Testing (190.22) NCD.
For Gamma Glutamyl Transferase:
Add ICD-9-CM codes 359.21, 359.22, 359.23, 359.24 and 359.29 to the list of ICD-9-CM codes covered by Medicare for the Gamma Glutamyl Transferase (190.32) NCD.
Delete ICD-9-CM code 359.2 from the list of ICD-9-CM codes covered by Medicare for the Gamma Glutamyl Transferase (190.32) NCD.
For Hepatitis Panel/Acute Hepatitis Panel:
Delete ICD-9-CM code 999.3 from the list of ICD-9-CM codes covered by Medicare for the Hepatitis Panel/Acute Hepatitis Panel (190.33) NCD.
Add ICD-9-CM codes 569.43, 787.20, 787.21, 787.22, 787.23, 787.24, 787.29, 789.51 and 789.59 to the list of ICD-9-CM codes covered by Medicare for the Fecal Occult Blood Test (190.34) NCD.
Delete ICD-9-CM codes 787.2 and 789.5 from the list of ICD-9-CM codes covered by Medicare for the Fecal Occult Blood Test (190.34) NCD.
Modify the descriptor for ICD-9-CM code 005.1 in the Fecal Occult Blood Test (190.34) NCD to read “Botulism food poisoning.”
Modify the descriptor for CPT code 82272 in the Fecal Occult Blood Test (190.34) NCD to read “Blood, occult, by peroxidase activity (e.g., guaiac), qualitative, feces, 1-3 simultaneous determinations, performed for other than colorectal neoplasm screening.”
To ensure proper reimbursement for these screening tests the correct procedure, diagnosis codes, and modifier (when appropriate) must be used.
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MLN Matters: SE0821 |
When filing claims for diabetes screening tests the following CPT codes, and diagnosis codes must be used to ensure proper reimbursement :
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HSPCS/CPT Codes |
Code Descriptors |
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82947 |
Glucose; quantitative, blood (except reagent strip) |
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82950 |
Glucose; post glucose dose (includes glucose) |
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82951 |
Glucose; Tolerance Test (GTT), three specimens (includes glucose) |
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Criteria |
Modifier |
Diagnosis Code |
Code Descriptor |
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DOES NOT MEET |
None |
V77.1 |
To indicate that the purpose of the test(s) is for diabetes screening for a beneficiary who DOES NOT meet the *definition of pre-diabetes, screening diagnosis code V77.1 is required in the header diagnosis section of the claim. |
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MEET |
-TS |
V77.1 |
To indicate that the purpose of the test(s) is for diabetes screening for a beneficiary who meets t he *definition of pre-diabetes, screening diagnosis code V77.1 is required in the header diagnosis section of the claim AND modifier “TS” (follow-up service) is to be reported on the line item. |
Medicare provides coverage for a maximum of two diabetes screening tests per calendar year (but not less than 6 months apart) for beneficiaries diagnosed with pre-diabetes.
Medicare provides coverage for one diabetes screening test per year (i.e., at least 11 months have passed following the month in which the last Medicare-covered diabetes screening test was performed) for beneficiaries who were previously tested and who were not diagnosed with pre-diabetes, or who have never been tested.
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CPT-4 Codes 88147 and 88148 Billing Restrictions Update |
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California - Medi-Cal CPT-4 Codes 88147 and 88148 may now be billed with modifiersRetroactive for dates of service on or after October 1, 2006, CPT-4 codes 88147 (cytopathology smears, cervical or vaginal; screening by automated system under physician supervision) and 88148 (screening by automated system with manual rescreening under physician supervision) are split-billed and may be billed with modifiers 26, TC or ZS. Claims denied inappropriately or paid incorrectly will be re-processed. |
Effective for dates of service on or after May 1, 2008, in regards to CPT-4 codes 80061 (lipid panel test) and 83721 (LDL cholesterol test), if the triglyceride level of the recipient is less than 400 mg/dl and both CPT-4 codes 80061 and 83721 are billed on the same date of service, for the same recipient, and by the same provider, the claim will be subject to a combination audit that will cut back the reimbursement so as only code 80061 is reimbursed.
Effective for dates of service on or after July 1, 2008, laboratory and radiology codes will be identified as either split-billable services or services that are not split-billable:
· Split-billable services: These services are separately reimbursable by different providers for a professional and technical component. The facility and physician each bill for their respective component of the service with modifier 26, TC or ZS.
· Services that are not split-billable: These services are not separately reimbursable by different providers for a professional nor technical component. Only one provider may be reimbursed for these codes. These codes must not be submitted with modifier 26, TC or ZS.
Laboratory and radiology services that were previously defined as “100 percent professional or 100 percent technical” will no longer be identified as split-billable, and must not be billed with modifier 26, TC or ZS.
Manual pages reflecting this policy will be released in the June Medi-CalUpdate and Family PACT Update along with a reprint of this article .
Effective for dates of service on or after July 1, 2008, the age limitation for CPT-4 code 87621 (infectious agent detection by nucleic acid [DNA or RNA]; papillomavirus, human, amplified probe technique) will be 21 to 99 years for the Medi-Cal program only.
If the State of California does not enact the Fiscal Year 2008-2009 budget by June 30, 2008, the Department of Health Care Services (DHCS) will direct the fiscal intermediary (EDS) to continue to pay Medi-Cal practitioners and institutional providers through the MPIP fund until the loan is exhausted, which is anticipated to be by July 17, 2008. After that date, Medi-Cal institutional providers will not receive payment until a budget is enacted.
Assuming the Fiscal Year 2008–2009 state budget will be enacted by no later than July 25, 2008 and effective August 7, 2008, reimbursement to Medi-Cal institutional providers will be held during the month of August and released throughout the month of September.
If the state of California does not enact the Fiscal Year 2008 –20 09 budget by June 30, 2008, DHCS will direct the fiscal intermediary, EDS, to implement provisions to continue processing and adjudicating claims as outlined below.
EDS will process and adjudicate claims for the following programs, regardless of date of service:
EDS will withhold all reimbursements for the following programs regardless of dates of service.
Effective for dates of service on or after July 1, 2008, claims submitted by provider types for which contingency funding is not available will continue to be processed, but reimbursement for these claims will be withheld until the state budget is approved and EDS receives approval from the state to resume reimbursement.
Since Fiscal Year (FY) 2004 – 2005, the last checkwrite in June of the FY has been delayed until the start of the next FY. Beginning with FY 2007 – 2008, an additional checkwrite for all fee-for-service providers will be delayed and paid during the next FY. The deferral of payment of the final two June checkwrites to the following FY will be on a permanent basis. In 2008, these two June checkwrites will be released to providers on July 2, 2008. The following programs are impacted by this delayed payment:
New York June 2008 Medicaid Update
Medicaid now reimburses for viral tropism testing. This test identifies patients who are likely to respond to the new HIV entry inhibitor drug, Selzentry . Currently, one method (Trofile assay) is eligible for coverage; other methods may be covered in the future. Laboratories are required to use MMIS procedure code 87999 to bill for a viral tropism assay test. The laboratory test is a covered service when clinically indicated, up to a maximum of two tests per 12-month period-per-patient.
All ordered tropism assays are reimbursable fee-for-service directly to the testing laboratory. This includes tests ordered for:
Only Medicaid-enrolled clinical laboratories with Department of Health approval to perform viral tropism assays are entitled to reimbursement.
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