Notice to Physicians
Dear MRHC Physician:
The pathologists and staff of McAlester Regional Health Center Laboratory appreciate your support and strive to provide you with quality services. We are committed and dedicated to continuously improving our services to you and your patients. We are required to inform you of changes in coding and billing practices mandated by the Centers for Medicare and Medicaid Services (CMS), formerly HCFA, and changes made by the American Medical Association in their Current Procedural Terminology (CPT). The Medicare fee schedule for laboratory services is available at the following Web site
http://www.cms.hhs.gov/ClinicalLabFeeSched/0a_overview.asp
Please contact us if you need help viewing these web sites or would like printed information on any items. The laboratory receives Medicare/Medicaid reimbursement equal to or less than the fee schedule. There are very few changes in laboratory CPT codes this year. CPT changes take effect on January 1.
An ongoing issue continues to be documentation of medical necessity, as defined by CMS through the Medicare regulations. It is imperative that you provide an ICD-9-CM code or written diagnosis for each test or procedure ordered. The ICD-9-CM code is preferred since it does not require any interpretation by our staff. The following Web site contains the Local Medical Review Policies (MRP) for Medicare in Oklahoma.
http://www.cms.hhs.gov/mcd/index_lmrp_bycontractor.asp.
For the National Coverage Determination (NCD) that are enforced at the national level, please see the following Web site:
http://www.cms.hhs.gov/mcd/index_list.asp?list_type=ncd
Please contact us if you need help viewing these Web sites or would like printed information on any items.
When we receive an order for a test that does not have a corresponding diagnosis (ICD-9-CM) based on the LMRP or NCD, we do not receive any reimbursement from Medicare. We are not allowed to bill the patient unless an Advance Beneficiary Notification (ABN) has been signed by the patient prior to collecting a specimen. Other tests not routinely covered by Medicare include screening tests (except Medicare approved annual screenings for PSA, Pap and fecal occult blood), tests ordered as part of a routine physical examination, and most experimental or research tests. These tests also require an ABN or we are not allowed to bill the patient.
CMS has implemented "National Coverage Determinations" (NCD) regarding clinical diagnostic laboratory services and they are continuously being amended. A lengthy Program Memorandum (AB-02-110) defines the original Medicare coverage limitations for these high volume laboratory tests. We will provide a copy of this 230 page document, if you request it.
The office of the Attorney General (OIG) of CMS requires us to inform you that "organ or disease related panels will only be paid and will only be billed when all components are medically necessary" and "the OIG takes the position that an individual who knowingly causes a false claim to be submitted may be subject to sanctions or remedies available under civil, criminal and administrative law." Supporting documentation of medical necessity must be maintained in your patient's medical record and must be available should an audit be performed.
For advice on medical necessity and/or appropriateness of test orders please contact one of our clinical consultants (a CMS Term defined in the clinical Laboratory Improvements Amendment) at 918-421-8174. Our pathologists are clinical consultants under the CMS definition. We welcome your recommendations for improvement of our services. Please let us know if we can provide assistance at any time for your pathology and laboratory needs.
