Industry News: Washington

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.

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.

On August 31, 2010, Noridian Administrative Services was notified that the Recovery Audit Contractor (RAC) had closed the technical component (TC) of Lab-Pathology query. On September 8, 2010, we received the RAC closure file for this query. The file contains a large number of claims that must be processed to stop the recoupment and re-issue payment. We are aware of the impact this has on our NAS provider community and are dedicated to processing these adjustments in a timely manner. We are currently working the file and will stop recoupment and re-issue monies collected, if applicable.

Noridian Administrative Services (NAS) is instructing providers how to bill for the lab test "Decision DX GMB" using CPT code 84999. In order to assist the treating physician in determining the patient’s treatment plan, this test analyzes the genetics of a glioblastoma brain tumor.
To avoid the denial of "service not medically necessary", the following descriptive statement must be included in Item 19 of the CMS-1500 claim form or its electronic equivalent.

Recent Comprehensive Error Rate Testing (CERT) analysis indicates increased errors when billing Prothrombin Time (PT). The PT must meet medical necessity criteria, even when done as part of a coagulation clinic or “incident to” other services.
Medicare pays for services based on medical necessity. These tests must be:

On July 21, 2010, CMS notified Noridian Administrative Services (NAS) that it would consolidate the Jurisdiction 2 and Jurisdiction 3 workloads and Medicare Administrative Contractor (MAC) contracts and issue a new request for proposal (RFP).

CMS has decided to cancel the J2 A/B MAC procurement and consolidate the J2 and J3 workloads into a new RFP that will be completed in the near future.