Industry News: Utah

The 2012 Coding Updates provides information on the new codes as well as the new Molecular Pathology Procedure codes. The update details what codes are covered and non-covered. Manual review is required prior to testing for some codes. Submit supportive medical record documentation for manual review prior to testing.

The NMP22 Bladder Check Test is used in the diagnosis and monitoring of bladder cancer. NAS will allow coverage and payment for this test when used to monitor bladder cancer between cystourethroscopy intervals.

Effective for dates of service on or after January 1, 2012, use the following codes:

• 86386 - Nuclear Matrix Protein 22(NMP22), qualitative and V10.51 - Personal history of malignant neoplasm of bladder

The NMP22 Bladder Check Test® is used in the diagnosis and monitoring of bladder cancer. NAS will allow coverage and payment for this test when used to monitor bladder cancer between cystourethroscopy intervals, effective for dates of service on or after September 19, 2011.

For claim payment, use the following codes:
• 88299 - Unlisted cytogenetic study, adding the description "NMP22" in Item 19 of the CMS-1500 form or the electronic equivalent. For Part A claims, add this notation to the remarks screen….and

The use of the Advance Beneficiary Notice of Noncoverage (ABN) allows the appropriate liability to be transferred to the patient in the event that the services do not meet reimbursement criteria. In ABN reviews performed by the CERT and other review contractors, the most common error seen involves the "Notifier(s)" section (A) of the form. Entities who issue ABNs are collectively known as Notifiers. These entities can include physicians, non physician practitioners, providers (including laboratories), and suppliers.

Noridian hosted a CERT and Laboratory Services Ask the Contractor Teleconference (ACT) on May 17, 2011. The following are some issues identified during the CERT audit.

• Incorrect coding a urinalysis with microscopy based on protocol. There must be a physician order for the test, Medicare does not accept protocols.
• Complete drug screening tests performed without the specific type of drug mentioned. For example is the drug screen specifically for opiates or barbiturates.

On December 20, 2010, the Division of Medicaid and Health Financing implemented a prepayment cost-saving editing solution to enhance the current editing within the Medicaid Management Information System (MMIS). The program incorporates correct coding principles, and industry accepted standards and guidelines to identify appropriate coding for provider billing and reimbursement.

In the near future, Medicaid will be adding additional modules to the existing prepayment editing tool. The new edits may affect claims and payment in the following areas:

• Unlisted procedure codes

NAS is providing the following clarification on the use of “standing orders” for laboratory tests. While Medicare generally requires that lab tests be individually ordered by the treating physician, in some circumstances, recurring orders for a lab test that are specific to the needs of an individual patient may be reimbursable.

Utah Medicaid currently sends providers notification of prior authorization decisions (both approvals and denials) via both facsimile and standard mail.

Beginning January 1, 2011, Utah Medicaid is discontinuing the practice of sending approval and denial notices to providers through standard mail. Providers will continue to receive these notifications via facsimile.

The following CPT code has been removed from requiring manual review:
87800 Infectious agent detection by nucleic acid (DNA or RNA), multiple organisms; direct probe(s) technique