Top 5 Industry News Topics of 2019

2. Calendar Year (CY) 2019 Annual Update for Clinical Laboratory Fee Schedule and Laboratory Services Subject to Reasonable Charge Payment

Section 1834A of the Social Security Act (“the Act”), as established by Section 216(a) of the Protecting Access to Medicare Act of 2014 (PAMA), required significant changes to how Medicare pays for Clinical Diagnostic Laboratory Tests (CDLTs) under the CLFS. The CLFS final rule, “Medicare Clinical Diagnostic Laboratory Tests Payment System Final Rule,” (CMS-162-F) was published in the Federal Register on June 23, 2016. The CLFS final rule implemented Section 1834A of the Act.

Under the CLFS final rule, reporting entities must report to the Centers for Medicare & Medicaid Services (CMS) certain private payer rate information (applicable information) for their component applicable laboratories. The next data collection period (the period where applicable information for an applicable laboratory is obtained from claims for which the laboratory received final payment during the period) is from January 1, 2019, through June 30, 2019, and the next 6-month window is July 1, 2019, through December 31, 2019 (the period where laboratories and reporting entities assess whether the applicable laboratory thresholds are met and review and validate applicable information before it is reported to CMS).

The next data-reporting period is January 1, 2020, through March 31, 2020, where applicable information is reported to CMS. This data will be used to calculate revised private payer rate-based CLFS rates, effective January 1, 2021. 

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3. Cigna Coverage and Policy Updates May 2019 Flow Cytometry and Pass Through Bills

After a recent review in coverage (as of May 2019), reimbursement, and administrative policies, Cigna has published several changes that will go live starting this week. Two of these updates will directly impact pathology practices and laboratories:

Flow Cytometry Policy Update

Flow cytometry is considered medically necessary for the evaluation of any of the following:

•  HIV Infection
•  Leukemia or Lymphoma
• Organ Transplants
• Carcinomas
• Primary Immunodeficiencies

While there is no NCD published by CMS, this Cigna Coverage Policy follows the same scope as published LCDs. Please reference your local Medicare Contractor’s LCD policy to understand how this update impacts your laboratory. 

Pass-through bills for laboratory services will be denied, effective May 21, 2019

Cigna will no longer reimburse for pass-through laboratory services. Pass-through billing occurs when providers bill for laboratory services they have not actually performed. These services are submitted with a Place of Service 11 (office setting) and have a modifier 90. The change will affect all laboratory service codes billed with modifier 90 in POS 11. Moving forward, the processing laboratories should bill Cigna directly in order to receive reimbursement. 

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4. Empire – BCBS New York – Changes to Timely Filing Requirements for Medicare Advantage

Effective September 1, 2019, we will amend the Medicare Advantage Attachment of your Empire Provider Agreement(s) to require the submission of all professional claims within ninety (90) days of the date of service. This means all claims submitted on and after October 1, 2019, will be subject to a ninety- (90) day timely filing requirement, and Empire will refuse payment if the claims you file to us are submitted more than ninety (90) days after the date of service.

Please note that all claims for commercial plans must continue to be submitted within 120 days of the date of service, and will be processed by Empire, in accordance with your Provider Agreement.

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5. CPT 87150 Reimbursement Change

Effective February 15, 2019, the Oklahoma Health Care Authority (OHCA) will only reimburse for CPT 87150 (culture typing; identification by nucleic acid [DNA or RNA] probe, amplified probe technique, per culture or isolate, each organism probed) in the outpatient hospital setting. 

Please note: When this service is performed in the inpatient setting, reimbursement is included in the DRG payment.

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