Laboratory and Molecular Diagnostic Services Program

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

To facilitate the provider community transition, Palmetto GBA will launch this program in two phases:

Phase 1 – Effective date: 09/01/2010

  • Providers make system changes to enter specific test/assay name into the description field
  • Providers may start to submit the test/assay name in the description field in the electronic format at the procedure code level (in the 4010 format for the 837 submission file, enter the information into the 2400 loop in the NTE segment)
  • Palmetto GBA starts to accept Coverage Decision Requests per process described below
  • Palmetto GBA identifies and accepts comments to facilitate the process

Phase 2 – Effective date: 12/1/2010

  • Palmetto GBA rejects claims submitted without the name of test/assay in the description field. Claim rejections have no appeal rights and must be resubmitted with the correct information.

SOURCE: Palmetto GBA

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