CMS

Adjudication of Reference Laboratory Service Claims

Independent Clinical Diagnostic Laboratory Billing

Effective Date: July 1, 2004
Implementation Date: July 6, 2004

An independent laboratory may bill for services they refer to another lab no matter where the reference lab is located. Labs must submit the zip code of the lab where the services were actually performed. The carriers' standard billing system will now price the payment for the referred services on the zip code where the service was performed.

Reference:  Medlearn Matters  MM3090.   Related CR:  3090, Transmittal 85.

Appeals = Redeterminations

Effective October 1, 2004

All first level appeals will now be called redeterminations. Redeterminations are the new first level of appeal under Section 521 of the Medicare, Medicaid and SCHIP Benefits Improvement and Protection Act of 2000 (BIPA).

Reference:  Appeals Process.  Related CR:  2620, Transmittal 97.

ICD-9-CM Update

Effective Date: October 1, 2004
Implementation Date: October 4, 2004

Medicare will no longer provide a 90-day grace period for the use of discontinued ICD-9-CM diagnosis codes. Physicians, practitioners and suppliers must bill using the updated codes.

Reference:  Medlearn Matters  MM3303.   Related CR:  3303, Transmittal 210.

National Coverage Determination Update

Effective Date: October 1, 2004
Implementation Date: October 4, 2004

Changes that will be included in the October 2004 release of the edit module for clinical diagnostic laboratory services are as follows.

1. Deleting the following diagnosis codes for the urine culture NCD:

• 584.5   Acute renal failure, with lesion of tubular necrosis
• 584.9   Acute renal failure, unspecified
• 586      Renal failure, unspecified

     Coverage for these codes will terminate for services furnished on or after October 1, 2004.

2. The following code is being added for the prothrombin time (PT) and partial thromboplastin time (PTT) NCDs.

• 729.81   Swelling of limb

     Coverage for this code will begin for services furnished on or after October 1, 2004.

3. The following code is being added for the prostate specific antigen (PSA) test NCD.

• 600.01    Benign prostate hypertrophy with urinary obstruction

     Coverage for this code will begin for services furnished on or after October 1, 2004.

4. To accommodate the new ICD-9-CM coding the following changes are occurring. These changes become effective for services furnished on or after October 1, 2004.

Adding a new ICD-9-CM code to the list covered by Medicare for urine culture NCD:

• 788.38

Adding new ICD-9-CM codes to the list covered by Medicare for HIV testing (diagnosis):

• 070.70
• 070.71
• 588.81
• 588.89
• V01.71
• V01.79

Terminating coverage of ICD-9-CM codes, effective with services furnished on or after October 12, 2004:

• V01.7
• 588.8

Adding new ICD-9-CM codes to the list that do not support medical necessity for the blood counts NCD:

• 521.06
• 521.07
• 521.08
• 521.10 - 521.15
• 521.20 - 521.25
• 521.30 - 521.35
• 521.40 - 521.42
• 521.49
• 524.07
• 524.20 - 524.37
• 524.39
• 524.50 - 524.57
• 524.59
• 524.64
• 524.75
• 524.76
• 524.81
• 524.82
• 524.89
• 525.20 - 525.26
• 618.00 - 618.05
• 618.09
• 618.81 - 618.83
• 618.89
• 692.84
• V72.40
• V72.41

Removing the following ICD-9-CM codes from the list that are no longer valid:

• 521.1
• 521.2
• 521.3
• 521.4
• 524.2
• 524.3
• 524.5
• 524.8
• 525.2
• 618.0
• 618.8
• V72.4

Adding new ICD-9-CM codes to the list covered by Medicare for the partial thromboplastin time NCD:

• 070.70
• 070.71
• 453.40 - 453.42

Adding new ICD-9-CM codes to the list of covered diagnoses for the prothrombin time NCD:

• 070.70
• 070.71
• 453.40 - 453.42
• 530.86
• 530.87

Adding new ICD-9-CM codes to the list of covered diagnoses for the serum iron studies NCD:

• 070.70
• 070.71

Adding new ICD-9-CM codes to the list of covered diagnoses for the collagen crosslinks NCD:

• 252.00 - 252.02
• 252.08

Removing the following ICD-9-CM code from the list that is no longer valid:

• 252.0

Adding new ICD-9-CM codes to the list of covered diagnoses for the blood glucose testing NCD:

• 491.22
• 707.00 - 707.07
• 707.09
• V58.67

Removing the following ICD-9-CM code from the list that is no longer valid:

• 707.0

Adding a new ICD-9-CM code to the list of covered diagnoses for glycated hemoglobin.

• V58.67

Adding new ICD-9-CM codes to the list of covered diagnoses for the lipid testing NCD:

• 588.81
• 588.89

Removing the following ICD-9-CM code from the list that is no longer valid:

• 588.8

Adding new ICD-9-CM codes to the list of covered diagnoses for the digoxin therapeutic drug assay NCD:

• 588.81
• 588.89

Removing the following ICD-9-CM code from the list that is no longer valid:

• 588.8

Adding a new ICD-9-CM code to the list of covered diagnoses for alpha-fetoprotein:

• 273.4

Adding new ICD-9-CM codes to the list of covered diagnoses for the gamma glutamyl transferase NCD:

• 070.70
• 070.71
• 252.00 - 252.02
• 252.08
• 273.4
• 453.40 - 453.42
• 588.81
• 588.89

Removing the following ICD-9-CM code from the list that is no longer valid:

• 252.0
• 588.8

Adding a new ICD-9-CM codes to the list of covered diagnoses for the hepatitis panel NCD:

• 070.70
• 070.71

Adding a new ICD-9-CM code to the list of covered diagnoses for the fecal occult blood test.

• V58.66

Reference:  CR 3358, Transmittal 225.

CCI

Changes to National Correct Coding Initiative Edits, Version 10.2

Correct Coding Initiative (CCI) Edits Version 10.2 (Effective July 1, 2004 - September 30, 2004) will be implemented. CMS implemented National CCI Edits in 1996 for the purpose of identifying and eliminating the incorrect codes of medical services.

• No Comprehensive/Compound code pairs were deleted from the list
• No Mutually Exclusive code pairs were deleted from the list
• No Comprehensive/Compound code pairs were deleted
• Two CP pairs were modified
• New CP Pairs contains newly added Comprehensive/Component pairs
• New ME Pairs contains newly added Mutually Exclusive pairs

The following CP pairs were modified:

Reference:  CCI Edits.

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