Palmetto GBA Laboratory and Molecular Diagnostic Services Program: update

As a CMS contractor, Palmetto GBA must determine reasonable and necessary services and apply fair reimbursement to services that are not listed in the current CMS laboratory fee schedule. For a wide range of laboratory and molecular diagnostic services, this responsibility is complicated by coding issues when

• Methodology-based code descriptions are used in place of the specific test performed

Palmetto GBA plans to launch the Laboratory and Molecular Diagnostic Services Program to

• Identify the specific services performed and billed to Medicare

This program will affect diagnostic services that meet the following criteria:

• Require/use more than one ©CPT code to identify the service
• Use the methodology-based ’stacking CPT codes’ (83890-83914), micro-array CPT codes (88384-88386), and cytogenetic CPT codes (88230-88291)
• Use an NOC (not otherwise specified) code

Phase 1 ñ Current time until Fall, 2011 (specific date to be determined)

• Laboratory providers will submit to Palmetto GBA their test catalog for procedures/services that

Require/use more than one CPT code to identify the service
Use the methodology-based ’stacking CPT codes’ (83890-83914), micro-array CPT codes (88384-88386) and cytogenetic CPT codes (88230-88291)

• Palmetto GBA will review all submitted test catalogs
• When necessary, Palmetto GBA will develop and publish specific procedure/service laboratory billing guidance
• Palmetto GBA will notify providers of services that do not meet Medicare coverage criteria.

Phase 2 ñ Fall, 2011

• Once notified, providers will need to adjust billing to the instructions provided following the reviews
• Palmetto GBA will reject claims submitted that are not in compliance with these revised instructions.

Coverage Decision Request Process

A coverage determination will be required for all new tests/assays prior to submission of claims and for any procedure/service determined by the contractor to need additional scientific documentation (see Phase I above). A provider making the request needs to include a comprehensive set of documents and submit them electronically to B.Policy@PalmettoGBA.com.