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Regulatory
Suggested Links:
- ABN: Medical Necessity
- CDC Drafting New Guidelines on Annual Tuberculosis Testing
- Chem-7 & SMA-7 Orders
- Deductible to be Waived for Colorectal Cancer Screening
- Environmental Care and Sampling (10/2008)
- Medicare CPT Code Changes for 2005
- Medicare Genetic Testing
- New Diagnosis Updates - 2008
- New Diagnosis Updates
- NPI
ABN: Medical Necessity
In it's zeal to catch providers who keep resubmitting claims until they find an ICD-9 diagnosis code that pays, the Centers for Medicare and Medicaid Services is placing the burden on Clinical Laboratories to acquire an ABN when the diagnosis does not meet the Medical Necessity guidelines CMS has initiated.
As of July 5th 2005, Medicare will no longer allow the review of previously denied claims.
MuirLab has an NCD manual available to physicians to help them with coding the 23 tests that CMS is monitoring. Once the claim has been denied the Lab cannot re-bill, which means your patients will have to pay. It is imperative that we receive the qualifying diagnosis when the order is placed.
[back to top]CDC Drafting New Guidelines on Annual Tuberculosis Testing
The Center for Disease Control (CDC) is currently drafting a fundamental change in the guidelines for testing health care workers for Tuberculosis (TB). The present CDC guidelines for such testing have been on the books since 1994, thus, these revisions are worth significant attention! The revision addresses the changes in epidemiology of transmission. The risk categories will be reduced from five to three. Low risk settings could eliminate annual tuberculin testing.
All hospitals would provide baseline screening of all health care workers upon hire with a two-step PPD or QuantiFERON test. In conducting risk assessment, hospitals need to recognize the fact that TB is more prevalent among foreign-born Americans, and more transmissible among people with HIV infection. The guidelines will have information about how to perform and interpret the QuantiFERON test. In December 2004, the FDA approved the new version of this test called QuantiFERON-TB GOLD.
The CDC promises to release guidelines within months (Spring/Summer 2005) on using this improved test. This test checks the blood for specific proteins of M. tuberculosis. Results are available in 24 hours. Cellestis Inc. claims that their test will have a negative response for people who have had Bacillus Calmette Guerin vaccine.
Chem-7 & SMA-7 Orders
The use of non-standard panel orders is in direct violation of the statute as mandated by Medicare and the OIG (Office of the Inspector General), and therefore deemed illegal. The continuation of this practice presents serious liability risk for both MuirLab and its customers.
Therefore, effective February 1, 2005 a new policy will be implemented. MuirLab will convert all Chem-7 and SMA-7 orders to Basic Metabolic Panels (BMP) which will then be ordered and resulted as such. This change will not negatively impact the timing of results reporting.
As always if you have any questions, please contact your MuirLab representative or our Client Service Department at (925) 947-4400.
Deductible to be Waived for Colorectal Cancer Screening
Starting January 1, 2007, Medicare will waive the annual Part B deductible for certain colorectal cancer screening procedures covered under the program's preventive services package. The waiver implements a requirement in the Deficit Reduction Act of 2005, said the Centers for Medicare & Medicaid Services (CMS Change Request 5127, July 21, 2006). Co-pay requirements will continue to apply.
Environmental Care and Sampling (10/2008)
Prior to 1970, hospitals regularly and routinely cultured air and environmental surfaces for microbial contamination. By 1970, both the CDC and the American Hospital Association were discouraging this practice. The 2003 CDC Guidelines for Environmental Control in Healthcare Facilities and the CDC Guidelines for Isolation Precautions: Preventing Transmission of Infectious Agents in Healthcare Settings 2007, do not recommend routine, random microbial sampling of the environment in healthcare facilities for several reasons, the foremost being that infection transmission was deemed less from the environment and more from hand contamination.
The CDC Guidelines for Environmental Control in Healthcare Facilities (published in 2003) state that environmental microbial sampling is indicated in 4 situations: 1) during the “…investigation of an outbreak of disease or infections when environmental reservoirs or fomites are implicated epidemiologically in disease transmission…”, 2) when warranted in a research study, 3) “…to monitor a potentially hazardous environmental condition to confirm the presence of a hazardous chemical or geological agent and validate the abatement of the hazard…”, and, 4) “…to evaluate the effects of a change in infection control practice or to ensure that equipment or systems perform according to specifications and expected outcomes.” The Guidelines add that “…sampling on an extended basis in the absence of an adverse outcome, is usually unjustified.”
Environmental surfaces can be a source of hand contamination and thus disease transmission. To reduce environmental hand contamination facilities should:
- Facilitate healthcare staff adherence to Standard Precautions and good Hand Hygiene as these remain the best method of reducing microbial transmission during routine healthcare activities. Routine hand washing should ensure a 20-second cleaning and scrubbing, include all surfaces of the hands and wrists, and utilize water and liquid soap or appropriate alcohol hand sanitizers. Patients should also be instructed in good hand hygiene and encouraged to wash their hands with soap and water or an alcohol hand sanitizer before leaving their rooms.
- Identify high-touch surfaces in patient rooms and common areas and ensure their cleansing and disinfection at least daily and when visibly soiled. Checklists and direct observation help housekeeping staff to not miss these frequently touched areas or items. Housekeeping staff should change or disinfect mop-heads and cleaning implements immediately after cleaning an isolation room or the room of a patient infected or colonized with difficult to eradicate organisms, such as Clostridium difficile, norovirus, or Acinetobacter baumannii.
- Ensure regular cleansing and disinfection of personal care and medical equipment, when visibly soiled, and prior to use on another patient. Patients infected or colonized with MDROs (Multiple Drug Resistant Organisms) or with difficult to eradicate organisms should have equipment dedicated to their use.
- Carefully consider roommate selection, especially when patients are colonized with an MDRO or a potential environmental contaminant. Patients colonized with an MDRO should have the opportunity to bathe or shower frequently and access to a fresh change of clothes at least daily.
- Ensure that manufacturer’s instructions are carefully followed when equipment, such as whirlpools and bathing tubs, hydrotherapy tanks and pools, ice machines, water dispensers, etc. are cleaned and disinfected.
Medicare CPT Code Changes for 2005
CPT PATHOLOGY/LAB CODES 2005: Additions, Revisions & Deletions.
The CPT coding update effective January 1, 2005, adds 19 new codes to the Pathology and Laboratory Medicine Section (80000 series), including 11 payable under the Medicare Part B lab fee schedule and eight payable under the physician fee schedule. Revisions to existing codes affect six codes in chemistry, hematology/coagulation, immunology, and microbiology, and two in surgical pathology.
The coding changes must be implemented January 1, 2005. Medicare will no longer grant a 90-day grace period to make the changes. (Refer to NIR 26, 2/Oct 25, 2004, p7)
NCD National Coverage Determination
Effective 10/01/04 there are several ICD-9 coding changes. Refer to CMS Medicare National Coverage Determination (NCD) Coding Policy Manual and Change Report October 2004 Revision I. For further information contact your MuirLab Sales Representative.
Medicare Genetic Testing
Currently, Medicare makes coverage decisions for genetic tests and services via a mix of national and local contractor policies. While this is reasonable the Secretary's Advisory Committee on Genetics, Health and Society (SACGHS) says, it has some drawbacks.
One remedy, the panel notes, is to encourage CMS to move ahead on implementing Section 731 of the 2003 Medicare Modernization Act. This requires CMS to develop a plan to evaluate new local coverage decisions with an eye toward ascertaining which should be adopted nationally and to what extent Medicare can achieve greater consistency in its coverage policies. We will continue to keep you informed as decisions are mandated.
New Diagnosis Updates
January 2008
Medicare and Private insurance companies are now becoming stricter in their coding regulations. If the diagnosis does not meet the requirement of the patient's necessity, the Private insurance or Medicare will not cover laboratory expenses. If the Medicare patients have signed an ABN, the patient will then be responsible for payment of the laboratory tests not covered. Please note: if the patient has Medicare, and the test being ordered is part of the commonly ordered 23 tests, please review the diagnosis codes with MuirLab's NCD Manual.
At times, physicians request that MuirLab re-bill a claim with new diagnosis codes. As the client, you will need to make sure the requests are made (on letterhead) specifying the new code and the reason it is being changed/added. Please make sure the letter is signed by the physician and not a member of the staff. According to United Government Services; "Submitting only an acceptable diagnosis is not enough". In order to resubmit a claim, MuirLab needs to make an appeal with the physician's records to support that the test was medically necessary. In an attempt to prevent unnecessary work, and avoid the patients being billed, please make sure you are checking the requisitions for valid diagnosis codes before the patient leaves your office. If you would like further information regarding Medicare Regulations, please visit www.ugsmedicare.com
Often times Diagnosis Codes are missed because staff is not completely educated on what a diagnosis is. Please remember that the meaning of a diagnosis code is associated with the signs and symptoms of the patient. Currently, MuirLab's Business Account Representative, in conjunction with the Diagnosis Code Department, are working together to educate MuirLab's clients on how to fully and accurately fill out requisitions.
In any given month, if a physician or physician's staff fails to send these codes, at month's end, the Diagnosis Department will send out a diagnosis list. Once this list is completed it must be signed and faxed back to MuirLab's Diagnosis Department. If a patient's information is not entered on this monthly report then that patient will automatically roll over into the next month's list. If patients are ignored for several months the result is that MuirLab is out of Compliance as it relates to the diagnosis codes. Please remember, if for any reason MuirLab is audited, you, as the client, will also be audited.
It is important to take whatever time is necessary to make sure the diagnosis codes are in the proper place. Doing so will ensure that your patients are free of needless phone calls and unnecessary bills. Your cooperation is extremely important. MuirLab appreciates those of you who diligently complete your respective lists!
New Diagnosis Updates
Medicare and Private insurance companies are now becoming stricter in their coding regulations. If the diagnosis does not meet the requirement of the patient's necessity, the Private insurance or Medicare will not cover laboratory expenses. If the Medicare patients have signed an ABN, the patient will then be responsible for payment of the laboratory tests not covered. Please note: if the patient has Medicare, and the test being ordered is part of the commonly ordered 23 tests, please review the diagnosis codes with MuirLab's NCD Manual.
At times, physicians request that MuirLab re-bill a claim with new diagnosis codes. As the client, you will need to make sure the requests are made (on letterhead) specifying the new code and the reason it is being changed/added. Please make sure the letter is signed by the physician and not a member of the staff. According to United Government Services; "Submitting only an acceptable diagnosis is not enough". In order to resubmit a claim, MuirLab needs to make an appeal with the physician's records to support that the test was medically necessary. In an attempt to prevent unnecessary work, and avoid the patients being billed, please make sure you are checking the requisitions for valid diagnosis codes before the patient leaves your office. If you would like further information regarding Medicare Regulations, please visit www.ugsmedicare.com.
Often times Diagnosis Codes are missed because staff is not completely educated on what a diagnosis is. Please remember that the meaning of a diagnosis code is associated with the signs and symptoms of the patient. Currently, MuirLab's Business Account Representative, in conjunction with the Diagnosis Code Department, are working together to educate MuirLab's clients on how to fully and accurately fill out requisitions.
In any given month, if a physician or physician's staff fails to send these codes, at month's end, the Diagnosis Department will send out a diagnosis list. Once this list is completed it must be signed and faxed back to MuirLab's Diagnosis Department. If a patient's information is not entered on this monthly report then that patient will automatically roll over into the next month's list. If patients are ignored for several months the result is that MuirLab is out of Compliance as it relates to the diagnosis codes. Please remember, if for any reason MuirLab is audited, you, as the client, will also be audited.
It is important to take whatever time is necessary to make sure the diagnosis codes are in the proper place. Doing so will ensure that your patients are free of needless phone calls and unnecessary bills. Your cooperation is extremely important. MuirLab appreciates those of you who diligently complete your respective lists!
NPI
As the standard, electronic claim formats (835i and 835p) have been implemented, it should come as no surprise that CMS has turned its attention to standardizing the data submitted in the electronic formats. One of the standardized data initiatives is to eliminate the current provider numbers, PIN's and UPIN's, and require a single, unique identification number. This new piece of data is called the Nation Provider Identifier or NPI.
The NPI is simply a ten digit number which is dubbed "intelligence free". This means the number is randomly selected, and not issued based on any pre-set sequence which would relate back to the type of service or specialty of the provider. Once you have obtained an NPI, it is yours for life. An NPI does not expire, and, if a provider gives up their NPI, it is not "recycled" and issued to another provider. Replacing an NPI will only be allowed under very rare and unique circumstances, so it is important that you keep all information attached to your NPI current. In fact, any changes to that information must be reported to the issuing authority within thirty (30) days of the change.
Any organization, partnership or individual provider who falls under the HIPAA guidelines must obtain an NPI. This includes Hospitals, Skilled Nursing Facilities, Independent Laboratories, Physician's and Physician practices, among others. The NPI structure divides all eligible providers into two groups: Type 1, which includes individual physicians, dentists and sole proprietors, or Type 2, which includes organizations, physician groups, hospitals, nursing homes, skilled nursing facilities and any corporation when an individual incorporates him/herself. If you are an individual who is a health care provider and who is incorporated or part of an incorporated practice, you may need to obtain an NPI for both yourself (as a Type 1 provider) and for your corporation (as a Type 2 provider). Hospitals and other larger organizations may also need to obtain multiple NPI's if they have subparts. For example, a hospital may need one NPI for the acute care facility, and a second NPI for its Home Health Agency. In this example, the HHA is a considered a subpart of the hospital. CMS and the NPI regulator has left the definition of what is and is not a subpart up to the providers. If you are not sure how to define it, a good rule of thumb is to obtain one NPI for each of the current Medicare provider numbers you or your organization uses.
NPI's can be obtained by applying on-line, or by submitting a paper application. The on-line site can be found at: https://NPPES.cms.hhs.gov. You can also print-off a paper application from this web site. The application requires about twelve piece of information, including the tax identification number (Tax ID) or Employer Identification Number (EIN) issued by the Internal Revenue Service (IRS), information about your license and a taxonomy code. Taxonomy codes relate to the type of service or specialty of the provider. A list of the codes can be found at : http://www.wpc-edi.com.
You can apply for an NPI number right now. CMS contractors (Fiscal Intermediaries or Carriers) must be able to accept an NPI starting January 3, 2007, although they will continue to require you also submit your Provider Number or PIN/UPIN as well. The official switch-over date for CMS to the NPI is May 23, 2007. By that date you must have your NPI, and be able to send it on your claim if you want to be paid by Medicare. Medi-Cal requires that you first register your NPI number with the Medi-Cal program. You must be registered by March 1, 2007, and use it as your submitting identification beginning May 23, 2007. To register with Medi-Cal, you can go to their web site at: www.medi-cal.ca.gov, or call 1-800-541-5555, press 11 and then 18 for more information.
It is imperative to you keep in mind that if you currently need the PIN/UPIN/Provider Number of another healthcare provider (i.e. admitting physician or the ordering physician), in order to submit a complete claim for your services, then on May 23, 2007, you will need to have that other providers NPI number in order to submit your claim to the payers. As of today, CMS does not have a mechanism to access a national data base of provider NPI numbers like they had available for UPIN numbers. We are all on our own to obtain the NPI number of other providers.
The commercial payers are required to accept the NPI data as of May 23, 2007, However, not even the Federal Government can dictate to a private company what they actually use to identify a provider. Considering the estimated costs to expand data bases to store two more digits to accommodate the date of "2000" at the turn of the century, there is no guarantee the insurance plans will want to spend the money to store another ten digits when they already use a unique number to identify payers (Tax ID's, EIN's or Social Security Numbers). It would be advisable, to ensure payment from any third party payer source, for all providers to continue to send those identifiers on their claims, along with the NPI. The bottom line for all providers still has not changed: he/she who matches the payers computer systems, gets paid.
Please include your provider name (either the individual or the organization), your NPI number and the name of the person/employee within the organization who is making the request along with a contact phone number and a return fax number.