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Medicare Lab Facts Presented by Tammy Ewers ,CPC POE
Stacy Mathison Manager Claims Sandy Anderson Manager Claims
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DISCLAIMER This information release is the property of Noridian Healthcare Solutions, LLC. It may be freely distributed in its entirety but may not be modified, sold for profit or used in commercial documents. The information is provided “as is” without any expressed or implied warranty. While all information in this document is believed to be correct at the time of writing, this document is for educational purposes only and does not purport to provide legal advice. All models, methodologies and guidelines are undergoing continuous improvement and modification by Noridian and CMS. The most current edition of the information contained in this release can be found on the Noridian website at and the CMS website at The identification of an organization or product in this information does not imply any form of endorsement. CPT codes, descriptors, and other data only are copyright 2016 American Medical Association. All rights reserved. Applicable FARS/DFARS apply. November 2016
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Agenda What's New Noridian Medicare Portal
General Coverage and Documentation Orders Intent Signatures MolDX Resources November 2016
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Medicare Beneficiary Identifier (MBI)
The Medicare Access and CHIP Reauthorization Act (MACRA) of 2015, requires removal of Social Security Numbers (SSNs) from all Medicare cards by April 2019. 11-characters in length Made up only of numbers and uppercase letters (no special characters) All eligible beneficiary will receive a new Medicare card for Medicare transactions like billing, eligibility status, and claim status. October 2016
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CERT Contractor Update
10/07/16- AdvanceMed will be performing all tasks All inquiries and records should be sent to CERT Documentation Center 1510 East Parham Road Henrico, VA Fax: Customer Service: Toll Free: November 2016
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Noridian Medicare Portal (NMP)
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Noridian Medicare Portal Home Page
October 2016
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NMP Registration Tips Ensure Provider Administrator is enrolled before other users attempt to enroll Ensure TIN/SSN and NPI combinations in EDISS Connect are correct Need Trading Partner ID (EDISS Connect) Unable to sign into EDISS Connect? Call (main provider #) or October 2016
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Portal Online Recording
Video Tutorial completed (18 mins.) Education/Schedule of Events (left corner) . October 2016
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General Coverage and Documentation
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November 2016
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Lab Documentation Requirements
November 2016
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Ordered and Referred Services Requirements & Documentation
Reminders and Updates
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Orders for Diagnostic Lab Tests
Order is defined as communication from treating physician or NPP requesting diagnostic test be performed A physician order is not required to be signed Physician must clearly document, in medical record his/her intent that test be performed November 2016
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Physician Intent Order or requisition signed by physician
Not valid on its own Notation in patient’s record is needed Verbal/telephone order documented at treating physician’s office from physician to be verified May need physician signature attestation November 2016
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Documentation Requirements
Maintain in patient medical records Orders/communications from ordering physician/ NPP Orders delivered in writing, via phone or ed Additional, conditional tests requested Test results Record date service was performed November 2016
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Signature Requirements
Unsigned physician orders or unsigned requisitions alone do not support physician intent. Physicians should sign all orders for diagnostic services to avoid potential denials. If the signature is missing on a progress note, which supports intent, the ordering physician must complete an attestation statement and submit it with the response. Attestation statements are not acceptable for unsigned physician orders/requisitions. November 2016
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Insufficient Documentation Errors
Signatures Missing Physician Order Related Orders Missing Orders Unsigned Intent to order not included in note Documentation to support intent to order (for example, a progress note or office visit note); and Documentation to support the medical necessity of ordered services. . November 2016
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Documentation Requirements Unlisted Codes
For unlisted lab codes: When billing electronically, Item 19 or narrative should have: Most complete, accurate description Don’t be brief Lots of characters to explain test performed Being descriptive will expedite pricing of claims November 2016
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Quality Testing Medicare does not pay for quality testing perform by labs for the sake of validating testing methods. November 2016
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National Correct Coding Initiative (NCCI) Edits
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CMS NCCI Page – Top Half November 2016
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Comprehensive/Component
Column 1 = Comprehensive/Major codes Column 2 = Component/Secondary codes Check both CCI column lists Component codes may be unbundled If Indicator 1 = may allow modifier 59 Cannot override edits with appeals Check quarterly code updates Notate CCI/MUE format – next slide November 2016
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Modifiers 59 and 76 Error: Modifier 59 no longer valid repeat modifier
Solution: Use appropriate repeat modifier Modifier 76 – Repeat Procedure by Same Physician Use for Anatomical pathology codes Modifier 91 Clinical lab codes November 2016
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Modifier 91 Modifier 91 - Repeat Clinical Diagnostic Laboratory Test to Obtain Multiple Results Same day/patient Do not use Repeat to confirm results Due to testing problems November 2016
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Repeat Modifier 91 – Not CCI
Date of Service Treatment CPT/ Modifier 03/09/16 Urinalysis, automated with microscopy 81001 Modifier 91 - Repeat Clinical Diagnostic Laboratory Test to Obtain Multiple Results Same day/patient Do not use Repeat to confirm results Due to testing problems November 2016
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NCCI Denials M-80: Not covered when performed during the same session/date as a previously processed service for the patient CO-B15: Payment adjusted because this procedure/service requires that a qualifying service/procedure be received and covered. The qualifying other service/procedure has not been received/adjudicated November 2016
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82947, Glucose, Quantitative, Blood
Don’t bill separately and part of panel on same day Ex: bundled with 80047, 80048, 80053, 80069, 80422, 80430, 80432, 80434, 80435 NCCI Indicator '1’ Separate, distinct service documented Submit with modifier 59 Ex: Different time of day November 2016
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83721, LDL Cholesterol Two lipoprotein tests cannot be billed on same day Do not bill separately and part of panel on same day Code Ex: 80061, 82465, 83700, 83701, 83704 NCCI Indicator '0' - do not bill '1’ Separate, distinct service documented Submit with modifier 59 Ex: Different time of day – medically necessary November 2016
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84479, Thyroid: Hormone Two thyroid tests cannot be billed on same day
Ex: Bundled into 84439 NCCI Indicator '0' - do not bill November 2016
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MUE’s Frequency HCPCS/CPT Code Practitioner Services MUE Values MUE Adjudication Indicator MUE Rationale November 2016
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ABN and Laboratory Services Reminder
Specimen at lab Lab reviews LCD/NCD Get ABN if necessary Specimen sent from office Office review LCD/NCD Send signed ABN to lab Complete entire form Maintain in patient medical record November 2016
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Claims Processing - MolDX
Stacy Mathison, Sandy Anderson
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Claims Processing - MolDX
Palmetto develops and coordinates with other MAC CMDs to develop consistent policies for MolDX. Monthly meetings are conducted with the MAC CMDs Discuss ongoing policy items Clinical utility of new or revised coverage articles and LCDs Effective dates 11/8/2018
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Claims Processing - MolDX
Noridian’s website contains the policies and provides a link to Palmetto General MolDX website. This website contains FAQs, registration information and billing requirements. Noridian Website: Active LCDs MolDX Subject 11/8/2018
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MolDX Noridian Website
November 2016
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Claims Questions Questions regarding MolDX claim processing:
Noridian Provider Contact Center (PCC) They will be able to assist you with your question They have been trained on MolDX processing JF PCC JE PCC 11/8/2018
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MolDX Policy Questions
Palmetto website Send policy and coverage questions to Palmetto at Dr. Jeter CMD Noridian Dr. Oakes CMD 11/8/2018
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Resources and Reminders
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Resources Additional Resources:
IOM Medicare Benefit Policy Manual Chapter 15 Section 80 - Requirements for Diagnostic X-Ray, Diagnostic Laboratory, and Other Diagnostic Tests Order – Defined in CMS IOM, Pub Ch. 15, Sec IOM National Determinations Manual (NCDs) IOM Chapter 16 Medicare Claims Processing Manual Change Requests (CRs) & Clarifications November 2016
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Resources Complying with Signature Requirements Clinical Lab Center
Change Request (CR) 6698 IOM Pub , Ch. 3, Section Clinical Lab Center CLIA Web page November 2016
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Clinical Diagnostic Lab Coding and Policy Manual
November 2016
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Specific NCD Information
Description CPT/HCPCS codes ICD-10 CM codes covered November 2016
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CERT Documentation Request Checklists
cert/index.html Ambulance Documentation Chiropractic Documentation Dialysis Documentation Evaluation and Management (E/M) Documentation Laboratory Documentation Physical, Occupational and Speech Therapies Psychiatric-Mental Health Documentation Radiation Oncology Documentation Radiology Documentation November 2016
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Questions Thank You!
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