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January 16,2004
UGS Questions and Answers (Part A)
The Members discussed the way questions were being submitted to UGS and WPS. WPS needed in depth questions so that they wouldn’t duplicate work. Examples of the issues are helpful. WPS also requested that claim ICN numbers rather than a beneficiary Medicare is sent via e-mail due to the privacy act.
Both UGS and WPS indicated that it would be helpful if the questions were screened for duplicates and clarification. If the providers submitted the question to customer service without a plausible answer or the provider cannot seem to get resolution to a question, Sharon and Teena agreed that they would be more than happy to assist the association.
Coding of claims is not a function of the Provider Education department. The medical review staff handles coding issues for WPS and Dr. Cope handles them for UGS.
We are going to three meetings a year. The next meeting will be in Madison on May 21, 2004 at 10:00 AM. The final meeting for the year will be in Milwaukee on September 17, 2004.
Questions and Answers:
1. When a patient has Medicare secondary and is being treated by a dialysis facility, who bills Medicare? Do the services fall under the ESRD composite rate then?
Answer: 50.1 - Laboratory Services Included in the Composite Rate
(Rev. 1, 10-01-03)
RDF-207.1, PM A-03-33
During the 30-month coordination period, the primary insurer should billed first and then Medicare. After the 30-month coordination period, Medicare is primary. When Medicare is primary the following instructions are followed:
The costs of certain ESRD laboratory services performed by either the ESRD facility or an independent laboratory are included in the composite rate calculations. Therefore, payment for all of these tests is included in the composite rate and may NOT be billed separately to the Medicare program. For an exception, see the discussion of ESRD related laboratory tests in Chapter 16 of this manual.
These tests are either performed by the facility, in which case payment is included in the composite rate, or by an outside laboratory for the facility, in which case the laboratory bills the facility, which is paid only under the composite rate. Finally, If the questions is, because MSP is involved does the billing of the labs change the answer is no. Bill the primary insurer first, then bill Medicare. Source CMS electronic manual on line (100-4 chapter 8). In addition view 100-4 chapter 16 ß40.6.2.1 and 40.6.22. Also view ESRD exceptions 100-2 chapter 2 ß 20.1 and 20.1.1.
2. When 88307 and 88325 are billed together from the hospital they are rejected. In the CCI file, there is an edit when 88325 is in column 1 and 88307 is in column 2. The effective date is 7/1/2003. A modifier is acceptable. What modifier should we use?
Answer: The use of modifier 59 would be appropriate.
3. Now that the Medicare reform bill has passed, this lifts the MSPQ requirement for referral specimens done by a hospital lab. What is the effective date regarding the rescinding of the MSPQ on non-patients?
Answer: This question has been forwarded to CMS by our MSP department. We have not received a response yet. When we do I will e-mail the answer to Paul to send to everyone.
4. When there is a test that is performed at a rate greater than the composite rate indicates (two Prothrombin tests within 1 week). The first prothrombin test is covered under the composite rate. How is the second test billed? Does the independent laboratory bill the carrier with the “CE” modifier? Or does the dialysis center to the intermediary?
Answer: UGS instructs independent dialysis providers in our ESRD manual at ugsmedicare.com under provider education to have the independent lab bill for the tests if they are not included in the composite rate. The independent lab should be billed to the Carrier.
5. When additional automated chemistry tests are performed outside of the composite rate ( ALT, direct bilirubin, chloride, and cholesterol) while the normal composite chemistry tests are also performed in accord with the monthly allowed testing, who bills the additional chemistry
tests? Does the independent laboratory bill to the carrier? Or the dialysis center as indicated in the "Medicare Claims Processing Manual" Chapter 16 section 40.6.1? Note: The Medicare Claims Manual only references submitting claims to the FI in this circumstance. Yet the "Medicare Claims Processing Manual" Chapter 8, section 60.1 says that for separately billable clinical laboratory tests labs must bill the carrier.
Answer: The test should be billed to the fiscal intermediary.
6. At the CMS Open Door Forum on December 12, 2003, there was the indication that when a complete CBC with automated differential (CPT 85025) is ordered, the provider should bill CPT code 85025 even if a manual differential is required to complete the ordered test. We are unaware of any published directions regarding this. Also, this response seems inconsistent with previous directions from WPS (January 17, 2003, Question 11) and UGS (April 11, 2003, Question 5) that indicated that the CPT codes should reflect the services that are actually performed (i.e. CPTs 85027 and 85007). What is the correct way of billing an order for a CBC with automated diff when the automated diff cannot be completed because of abnormal cellular components and a manual differential is required to complete the order?
Answer: See response to question number 7.
Background
CLMA: CMS Holds Last Open Door Forum for 2003 (12/12/03)
Correct Billing of Manual Differentials
CMS again reiterated the agency's policy with regard to billing manual differentials. If a complete blood count (CBC) with automated differential is ordered, the provider should bill CPT code 85025, Complete CBC, automated (Hgb, Hct, RBC, WBC, and platelet count) and automated differential WBC count even if a manual differential is required to complete the ordered test.
UGS CLMA Quarterly Minutes April 11, 2003
Are there CCI edits regarding the following 2 CPT codes being mutually exclusive 85025 and 85007? Last time the question was asked UGS we were told that we could bill both codes.
Answer: The CCI edit for the codes above is a component of comprehensive procedure edit. The narrative says there is misuse of column 2 code with column 1 and even with a modifier on the claim the system will not accept the combination for payment. As a provider you might consider 85007 and 85027 as HCPCS codes for the test you are performing.
WPS CLMA Meeting January 17, 2003
Currently, we have a charge edit rule setup so that if a manual diff is required, we get the single billing/CPT code for CBC with manual diff. In 2003, we needed to bill for two CPT codes, 85027 and 85007. One of our references says, "Because two codes not report the tests, you should be alert for payer restrictions on reporting these services together". That is very key phrase, and we are wondering if you have any idea how this will be handled?
If a CBC and manual differential are performed, is it appropriate to bill 85027 and 85007?
Answer: The combination of billing these two codes is not included in CCI. As long as you are performing the description of each of these codes and not duplicating any part, then it is appropriate to bill them together. CMS has not setup any edits for billing this combination. The individual carriers cannot alter any edits for procedure codes that are covered in the NCD. A good resource for determining a decision to these types of questions is the "Laboratories Test Handbook".
7. At the CMS open door forum on December 12, 2003, there was the indication that when a complete CBC with automated differential (CPT 85025) is ordered, the provider should bill CPT code 85025 even if a manual differential is required to complete the ordered test. We are unaware of any published directions regarding this. Also, this response seems inconsistent with previous directions from WPS (January 17, 2003, question 11) and UGS (April 11, 2003), question 5) that indicated that the CPT codes should reflect the services that are actually performed (for example, CPTs 85027 and 85007). What is the correct way of billing an order for a CBC with automated diff when the automated diff cannot be completed because of abnormal cellular components and a manual differential is required to complete the order?
Answer: As stated by CMS on 12/13/2003, it is the code 85025 only that is reportable.
8. The description of CPT code 87046 was updated for 2004 to clarify that the bacterial culture was aerobic. The new description no longer includes the words "each plate". Is it still appropriate to bill this code for each additional stool pathogen isolation and examination
performed by a plate?
2003 description: Culture, bacterial; stool, additional pathogens, isolation and preliminary examination (e.g., Campylobacter, Yersinia, Vibrio, E coli O157), each plate
2004 description: Culture, bacterial; stool, aerobic, additional pathogens, isolation and presumptive identification of isolates
Example: A stool culture is requested to test for shigella, salmonella, campylobacter and E coli. Currently, a claim would be submitted for:
87045 - Isolation and preliminary examination for Salmonella and Shigella
87046 - Isolation and preliminary examination for Campylobacter
87046-76 - Isolation and preliminary examination for E coli O157
Answer: You can continue to bill as your example indicates, but modifier 76 is not needed.
9. Normally, we do an automated CBC with diff, CPT 85025. When the automated diff is not valid, we do a manual differential. Would it then be appropriate to bill for the CBC without diff (85027) and manual diff (85007)?
Answer: See the response to number 7.
10. On page 20 of the Medicare Memo 2003-11.0 of 11/19/2003 there is a table which shows HCPCs codes that may not be paid separately from SNF PPS. Among theme is CPT code 36430, transfusion, blood or blood components. Does that mean if a Part A SNF patient is sent to a hospital for an outpatient blood transfusion that the blood product (P9021), type (86900), screen (86900), screen (86850), and crossmatch (86922) should be billed to Part B but the transfusion cost (36430) to the SNF as a part of the SNF PPS?
Answer: The criteria for SNF consolidated billing has not changed. If the patient is at a Part A level of care in a SNF, the hospital looks to the SNF for payment if the situation does not fall under the exclusions that are emergency room or surgery. The SNF would have to discharge the patient in order for the hospital to bill.
11. If a hospital owns a clinic (not-provider based status), and that clinic should refer their lab work to an independent reference laboratory would the services at the clinic be considered outpatient services and need to be billed to part A or would the services at the clinic be considered stand alone and fall under part B billing?
Answer: If the clinic does not have provider based status it would fall under Part B. The hospital would have applied for provider based status or was deemed provider based then yes the criteria is the same.
12. Bills submitted to UGS--we are submitting 85014 (HCT), 85018 (HGB), and 85048(WBC) and UGS is rolling it up to 85022 which is an deleted CPT! Should we be submitting 85027 (CBC) even though we aren't doing the RBC or platelet?
Answer: The correction is planned for release on 3/1/2004. Please call customer service after 3/1/2004 if it has not been corrected. The number is 877-309-4290.
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