Industry News: Palmetto Gba

Palmetto GBA has completed the Afirma assessment and determined that the test meets criteria for analytical and clinical validity, and clinical utility as a reasonable and necessary Medicare benefit. Effective January 1, 2012, Palmetto GBA will reimburse Afirma services. Palmetto GBA expects this test will be performed once in a patient's lifetime.

Medicare Part A and Part B MAC for Jurisdiction 1

CMS has directed Palmetto GBA to expand the J1 Molecular Diagnostic Services Program (MolDx) to identify and establish coverage and reimbursement for molecular diagnostic tests. The MolDx program is powered by the McKesson Diagnostics ExchangeTM to enable standardized, time bound test registration and coverage determination processes.

Effective for dates of service 02/27/2012 and forward, Palmetto will consider "non covered" all non-standardized organ or disease-oriented panels that meet the following criteria:

1. Are non-FDA cleared laboratory developed tests (LDTs)
2. Are performed or marketed by a sole source, hospital, or reference laboratory
3. Have not received a specific AMA CPT code
4. Have not obtained an NCD or LCD coverage determination from Palmetto GBA
5. Tests that require multiple CPT codes in order to submit a claim for a single assay/test

Palmetto GBA J1 Part B Medical Review has completed the service specific complex review for radiology services (CPT codes 71010 and 71020) for February 11, 2011, through April 11, 2011, in southern California. There were 19,001 claims reviewed, out of which 8,879 claims were denied. This was a 46.3 percent charge denial rate.

The top denial reasons identified from the review are:
• 47 percent: Missing Physician order
• 27 percent: Missing or incomplete documentation for this date of service definition
• 9 percent: Missing radiology report

The J1 Part B Medical Review top denial reason codes article is now available on the J1 Part B Web site.

Top Laboratory Denial Reason Codes

1. Denial Code N102 - Lack of Response to Medical Record Request
2. Denial Code 50 - Payer deems the information submitted does not support medical necessity of services billed.
3. Denial Code N237 – Documentation Is Illegible
4. Denial Code N29 - Documentation requested for the date of service was not received or was incomplete.

Palmetto GBA mailed out an important letter regarding the recent Comprehensive Error Rate Testing (CERT) report to the J1 Part B provider community in April 2011. The soon to be released November 2010 Medicare fee-for-service (FFS) claims error rate will unveil a paid claims error rate result nearly TWICE the national average for services rendered by Part B health care professionals in the J1 region (an approximate 22% error rate for California, Nevada and Hawaii).

Palmetto GBA will allow up to four glycated hemoglobin tests (CPT code 83036) for each beneficiary per year. Additional A1C test(s) performed are not considered reasonable and necessary for most diabetic patients.

The provider will need to submit a redetermination request for denied claim(s). Medical rationale for additional test(s) should be attached to the redetermination request showing the medical necessity for any additional test(s).

The comment period for Bladder Tumor Markers Local Coverage Determination (LCD) J1B-10-0005-L became effective on July 9, 2010. The comment period ended on August 30, 2010. Comments were received from the provider community and can be reviewed.

The implementation of the ANSI 837I v5010A2 presents substantial changes in the content of the data institutional providers will submit with their claims. In order to help institutional providers prepare for these changes, Palmetto GBA has created a CMS-1450 claim form crosswalk to the ANSI 837I v5010A2. This crosswalk will help institutional providers with correct claims submission during and after the transition to the ANSI 837I v5010A2.