October 18,2002 UGS Questions and Answers: 1.I just finished reading Program Memo AB-02-129 regarding claim processing requirements of Negotiated Rulemaking. Item C within the policy section states “Diagnoses are not required on claims for lab services from hospitals or independent labs unless there is a NCD, a LMRP, or notification for the need for diagnoses due to medical review.” Will UGS accept a claim from a hospital lab after November 25, 2002 with (out) diagnosis? Answer: UGS will not accept a claim from a hospital lab after November 25, 2002 without an ICD-9 diagnosis. The negotiated rulemaking policies to which the PM refers are NCD’s. In addition, we will soon publish on our web-site notification that we require a diagnosis for any lab claim, whether related to these NCD’s or not. 2.We’ve had trouble getting paid for the brain natriuretic peptide test, CPT code 83520. How should this be handled? Answer: It was confirmed at the Meeting on 10/18/2002 that this question was for WPS. 3.When will UGS reprocess lab charges from November, 2001-March, 2002 regarding the following tests: Digoxin, glycated, lipid panels, PSA, thyroid, and urine bacteria? UGS has continued to work on the adjustments indicated above. The workload is large for WI. Michigan claims were also affected by the problem and their workload was a little smaller so we adjusted those claims first. As soon as the MI workload is complete, we will put an update on the Morning News regarding the WI claims. 4.If an RN does an ECG or Nebulizer therapy can we still charge for either and the medication (with the nebulizer) or, is this considered part of the nursing service and therefore cannot be billed separately? Answer: There is no charge for “nursing service”; if you are billing with 99211 to cover nurse time that is inappropriate. There are APC’s for ECG & Nebulizer. 5.When doing a Metered Dose Inhaler instruct are we allowed to charge for this and if so under what description aerosol? Answer: MDI instruct cannot be billed. 6.Are they (UGS,LLC) going to publish the NCDs on their web-site? Answer: No. 7.Is UGS required to convert NCDs into LMRPs for the NCDs to be effective? Answer: No. Notable: The Centers for Medicare and Medicaid has instructed all contractors to cease e-mail communication with Health Insurance Claim numbers in them. Security is a major concern and doesn’t exist at this time. Therefore, all communication should be sent through the mail or fax. Discussion * There is a discrepancy in AB-02-129 regarding the ABN documents as a requirement for providers. WPS and UGS confirmed with CMS that the forms in the PM are required when a provider issues an ABN. * Can we (UGS) hold the (NCD) lab claims for the last two weeks of December 2002 since the NCD codes will not be ready until January 2003? No, we will not hold claims. To avoid adjustments the providers have the option to hold their claims until January 2003. * After January 2003 will we (UGS) re-run the claims so that we are sure we paid the NCD labs correctly? No. * What date should the providers use on refrigerated specimens that are a few weeks old? UGS, LLC doesn’t have an official answer at this time. In general, once a specimen is stored the “archive” definition under the Date of Service section in PM AB-02-129 will probably apply. WPS Questions and Answers 1. I just finished reading Program Memo AB-02-129 regarding claim processing requirements of Negotiated Rulemaking. Item C within the policy section states "Diagnoses are not required on claims for lab services from hospitals or independent labs unless there is a NCD, a LMRP, or notification for the need for diagnoses due to medical review." Will WPS accept a claim from an independent lab after November 25, 2002 with NO diagnosis? Answer: At this point, I was unable to get a definite answer to this question, and it needs to be looked into further. As it stands, items 21 and 24e of the CMS-1500 claim form (and their respective electronic records) are required elements for claim submission. I will email the group with an answer soon. 2. What is WPS' action plan for paying us on the Negotiated Rule Making 23 tests effective in late November? Answer: The 23 NCDs for clinical diagnostic lab services will become effective on November 25, 2002. Contractors have been instructed to ensure that no LMRPs conflict with the NCDs by this time. The NCDs will replace the following Wisconsin LMRPs as of 11/25/02: PATH-009 Fecal Occult Blood Testing PATH-010 Blood Counts Including Hemograms, White Blood Counts, Red Blood Cell Counts and Platelet Counts PATH-013 Thyroid Function Testing PATH-014 Glycated Hemoglobin and Glycated Albumin PATH-017 Lipid Testing (Lipids, Cholesterol, Triglycerides) PATH-019 Digoxin Therapeutic Drug Assay PATH-020 Prothrombin Time PATH-021 Serum Iron PATH-029 Prostate Specific Antigen - Screening and Diagnostic Tests and Procedures PATH-030 Immunoassay for Tumor Antigens GU-011 Urine Cultures Once these LMRPs are replaced, the edits and audits for these policies will no longer be in place, and, therefore, the claims should not deny. By January 1, 2003, the system edits for the NCDs will be available and implemented. FYI: NCDs where a local medical review policy did not exist previously in our 4-state jurisdiction: Collagen Crosslinks Alkaline Phophatase Human immunodeficiency Virus Testing –diagnostic Aspartate Aminotranferase Human immunodeficiency Virus Testing –Monitoring Hepatitis Function Panel Alanine Aminotransferase Hepatitis Panel 3. We receive denial code CO-16 for all 83520 codes submitted (test BNP). After submission of notes, we receive denial code PR-56. This test will have its own CPT code for 2003 (8388X). Are we currently coding it incorrectly which results in the denials, or is this test not considered a covered service of the Medicare program and billable to the patient (no ABN is on file)? Answer: At this time, Medicare does not cover this test because the usage of it is still being investigated. Per the FDA, BNP is used as an aid in the diagnosis of CHF. Per Dr. Boren, Illinois CMD, BNP may become a Medicare covered test within the next year for this reason only. Because it is a non-covered test by Medicare at this time, it would be billable to the beneficiary, as it would deny PR-56 (Claim/service denied because procedure/treatment has not been deemed “proven to be effective” by the payer). 4. We are seeing denials on B-Type Natriuretic (BNP) CPT code 83520 stating the claim lacks information for adjudication/the patient's medical record for this service was not submitted with the claim as required. How are we to obtain payment on this test? Answer: The claim must be submitted with documentation. It will then be sent to Medical Review for determination, and, as mentioned, the service will then be denied as investigational (PR-56). It does not appear that modifier GY could be used with this procedure because that modifier generates a denial that does not match the correct denial for this service at this time. 5. We have received denials on CPT Code 83894 (HPV Gel Elect) and 83898 (HPV DNA Amp) the denial is payment adjusted because treatment was deemed by the payer to have been rendered in an inappropriate or invalid place of service. How can we get paid for this? Answer: This denial is correct because these codes cannot be billed by the pathologist. According to the MPFSDB, these are X-status codes, meaning that they are “not in the statutory definition of ‘physician services’ for fee schedule payment purposes.” Therefore, no payment will be made under the physician fee schedule. The services should be billed under the independent lab’s supplier number with POS 81. 6. We are also seeing a CO-16 denial (Remark M127 - The patient's medical record for this service was not submitted with the claim as required) on Apolipo tests, CPT code 82172. How can we get paid? Answer: For payment to be considered, documentation must be submitted with the claim. For electronic billers, there is a record in which the provider must indicate that they have documentation (the field will indicate a Y or N). With this indication that documentation is available, the system will autodevelop. Once the documentation has been received, the claim will be routed to Medical Reviews for determination. In the example given, there was no indication that documentation was available. Therefore, the system autodenied the service. 7. Can you please address the payment methods for the pathology scenarios that were submitted to you by Marshfield Labs? Answer: The three examples that were submitted to WPS have recently been reprocessed and paid. If you continue to receive denials upon first submission of these claims, please let us know. 8. Physicians order cholesterol and triglycerides on body fluid. What CPT codes do you recommend to use for billing body fluid as opposed to serum? PATH017 - focus is on serum cholesterol and trig. The CPT codes are 82465 (serum cholesterol) & 84478 (triglycerides - specimen not specified). The diagnosis in PATH017 does not support the clinical reasons why the testing may be ordered on body fluid. How do you recommend billing these services? Answer: For this question, more information has been requested. Once received and researched, an answer will be emailed to the group. 9. In the past, we were advised (WMGMA/WPS Meeting, December 3, 2001) that we were to continue using the special waiver of liability form (CommuniquÈ, March 1998) developed for pap smears and mammograms rather than the new standard ABN format released by CMS for October 1, 2002 implementation. Are we to continue to use the special format for pap and mammogram services or are we to use the new ABN for all services? Answer: The new ABN forms were mandatory as of 10/1/02 and should be used for all services. The special WOL forms for paps/mammograms is no longer valid, nor is any other form an entity may have developed for their own use. The new forms and instructions can be found on the CMS web site (PM AB-02-114). http://www.cms.hhs.gov/medlearn/refabn.asp