Industry News: Medicare

Palmetto GBA has completed the HERmark assessment and determined that the test meets criteria for analytical and clinical validity, and clinical utility as a reasonable and necessary Medicare benefit. Effective December 9, 2011, Palmetto GBA will reimburse services for HERmark.

Medicare Part A and Part B MAC for Jurisdiction 1

This article introduces two CPT Codes to report in situ hybridization (e.g., FISH) testing for bladder tumor markers: 88120 and 88121. Palmetto GBA will only cover these tests when performed using validated assays such as the UroVysion Bladder Cancer Kit, an assay performed on urine specimens from persons with hematuria who are suspected of having bladder cancer. It also serves as an aid for initial diagnosis of bladder carcinoma and subsequent monitoring for tumor recurrence in patients previously diagnosed with bladder cancer.

WPS Medicare has noted an increase in the number of Comprehensive Error Rate Testing (CERT) errors related to CPT codes 85025 and 85027. Based on review of documentation, either the test administered or the physician order did not support the service billed to Medicare.

As of this Oct. 1, 2003 all laboratory claims must contain a valid ICD-9 diagnosis code, with the service coded to the highest degree of specificity. Otherwise, they will be returned as "unprocessable." The change applies to both electronic and paper claim formats.

Effective with services received on or after April 1, 2004, Medicare will implement a new payment policy for referred lab services by an independent lab "Specialty 69--Independent Laboratory".

Effective January 1, 2004, laboratories should add the GY modifier to the CPT procedure codes for any service where the appropriate diagnosis for that service is on the list of diagnoses that are not covered by Medicare.

In November 2002, Medicare implemented 23 national coverage determinations (NCDs) for clinical diagnostic laboratory services. These NCDs are specific down to the ICD-9-CM code level and included lists of ICD-9-CM codes that are covered and those that are not covered by Medicare.

Through an amended national coverage determination, effective for dates of service January 1, 2004 and forward, Medicare coverage is being expanded for screening for early detection of colorectal cancer by adding an additional fecal occult blood test (iFOBT, immunoassay-based) that can be used as an alternative to the existing gFOBT, guaiac-based test.

Medicare patients aged 50 and over can only receive one FOBT per year, either G0107 (gFOBT, or guaiac-based) or G0328 (iFOBT, or immunoassay-based).

Procedure G0328 is payable under the clinical lab fee schedule.

An article published in Medicare B Resource for June 2003 (page 21) announced that Medicare considered High sensitivity C-reactive protein to be used as a screening test only and therefore not reimbursable. This policy is being revised based on updated information. High sensitivity C-reactive protein (hsCRP) (CPT code 86141) has been found to be related to or somewhat predictive of atherogenic risk for cardiovascular disease or stroke. Recent literature supports this as the principal use of hsCRP.