Audit Sheet Instructions: Hematology
PAGE:1 of 5 / REVISED:
APPROVED: 01-16-1998 / RETIRED:
EFFECTIVE DATE: 01-16-1998 / REFERENCE NUMBER: BOS.LAB.002
SCOPE: : Business Office Nursing
Admitting Laboratory
Finance Health Information Management
Administration Utilization Review
Revenue Integrity
PURPOSE: To ensurehematology services are billed in accordance with Medicare, Medicaid,
and other federally funded payor requirements. Hematology services must not be “unbundled”
(i.e. the use of two or more CPT billing codes in lieu of one inclusive code), double billed, or
improperly submitted (i.e. for tests not ordered, for tests not medically necessary, etc.)
POLICY: Hematology procedures which include three or more components must not be “unbundled” into individual procedures. Only one hematology panel per outpatient per date of service for federally funded programs may be billed. Hematology services billed to a federally funded program must be based on a written order and be medically necessary.
PROCEDURE: The following steps must be performed to ensure hematology services are billed in accordance with Medicare and other federally funded programs.
IMPLEMENTATION
- Laboratory personnel must review and ensure applicable revisions are made to the chargemaster and related Laboratory and Order Entry masterfiles/dictionaries as follows:
- Assign CPT /HCPC codes as defined below and attach revenue code 305 in accordance with the UB-92 Manual for hematology components and panels.
85007 Manual diff WBC count
85009 Buffy coat diff WBC count
85013 Spun hematocrit
85014 Hematocrit - not spun
85018 Hemoglobin
85041 RBC
85048 WBC
85595 Platelet, automated count
Panels:
85021 Hemogram, automated (RBC, WBC, Hgb, Hct, and indices only)
85022 Hemogram, automated, and manual differential WBC count (CBC)
85023 Hemogram and platelet count, automated, and manual differential WBC count (CBC)
85024 Hemogram and platelet count, automated, and automated partial differential WBC count (CBC)
85025 Hemogram and platelet count, automated, and automated complete differential WBC count (CBC)
85027 Hemogram and platelet count, automated
85031 Blood count; hemogram, manual, complete CBC (RBC, WBC, Hgb, Hct, differential and indices)
b. Three or more components must be bundled to the appropriate panel therefore, remove charge explosions from hematology panels which contain three or more components. Two or less components may be ordered as a “panel” but must billed as individual components, such as H & H (Hemoglobin and Hematocrit).
- Business office personnel must establish edits in the electronic billing system which:
b. Bundle components to the panel level when three or more components are charged on the same patient on the same date of service.
3. Laboratory and business office personnel must educate all staff associates responsible for ordering,
charging, or billing laboratory services on the contents of this policy.
4. The Facility Billing Compliance Committee must complete the attached Audit Worksheet in accordance with the “Billing - Auditing Procedures” Policy, Reference Number BOS.GEN.001.
5. Business office personnel must identify intermediary interpretations which vary from the interpretations in this policy. Specific intermediary documentation related to the variance(s) must be obtained and faxed to 615-344-2734, Attn: Billing Compliance - Intermediary Interpretations.
DAILY
1. It is recommended but not required that laboratory personnel review daily charge reports (e.g. Ancillary Charge Report, NPR charge reports, etc.) to ensure compliance with this policy as follows:
a. No duplicate hematology components are billed to federally funded programs.
b. Only one hematology panel is billed per outpatient per date of service for federally funded programs.
c. Three or more hematology components must be bundled to the appropriate panel defined as follows:
85021 85022 85023 85024 85025 85027 85031
85007 85007 85007 85007 85007
85009 85009 85009 85009 85009 85009
85013(14) 85013(14) 85013(14) 85013(14) 85013(14)85013(14) 85013
85018 85018 85018 85018 85018 85018 85018
85041 85041 85041 85041 85041 85041 85041
85048 85048 85048 85048 85048 85048 85048
85595 85595 85595 85595 85595
Any exceptions noted on the daily charge reports should be corrected on the individual patient accounts. This will ensure that your accounts receivable system remains updated with actual billing data.
- Business office personnel must review electronic billing edit / error reports daily and perform the following:
b. Bundle hematology components into the appropriate panel when three or more are billed.
c. Identify presence of more than one hematology panel and eliminate the least comprehensive.
d. Modify number of units and related charges in the electronic billing vendor system to reflect the appropriate charge and CPT for the panel being billed.
e. It is recommended but not required to modify the number of units and related charges in the Accounts Receivable system to match the corrected claim in electronic billing system. (Note: Utilize ancillary charge codes rather than correcting claims with adjustment codes. Corrections made subsequent to final bill should be processed through your patient accounting system late charge cycles.) This will ensure that your accounts receivable system remains updated with actual billing data.
It is the responsibility of the Chief Financial Officer to ensure adherence to this procedure.
EXAMPLES:
1. A. Doctor orders CBC with Diff.
B. The CBC is performed on a automated system and you report complete CBC with platelet, indices and auto diff.
BILL: CPT code 85025 (Automated Hemogram with Platelet and auto diff)
2. A. Doctor orders CBC no diff (Hemogram).
B. You report results which are abnormal.
C. Doctor then orders complete CBC w/ diff on the same sample.
D. You report CBC, platelet, indices, and diff (performed on automated system).
BILL: CPT code 85025 (Automated Hemogram with Platelet and auto diff)
3. A. Doctor orders CBC w/ diff.
B. You perform test on an automated system that includes indices, platelets.
C. You perform a spun hematocrit to confirm a discrepancy between the hemoglobin and hematocrit values.
BILL: CPT code 85025 (Automated Hemogram with Platelet and auto diff)
4. A. Doctor orders Hemoglobin and Hematocrit and a White Blood Count.
B. You perform these three tests on an automated system..
BILL: CPT code 85021 (Automated Hemogram)
5. A. Doctor orders a CBC with diff.
B. You perform this on an automated system.
C. Manual Diff is performed due to abnormal values.
D. You report CBC, Platelet, Indices, and Manual Diff results.
BILL: CPT code 85023 (Automated Hemogram with Platelet and manual diff )
Special Considerations:
DO NOT CHARGE FOR services reported as a result of a calculation. This includes CPT 85029 and 85030.
DO NOT CHARGE FOR both manual and automated differential on the same patient for the same date of service.
DEFINITIONS:
Encounter: Each date of service.
REFERENCES:
Medicare Reimbursement Manual for Clinical Laboratory Issues; National Edition, 1997. Washington G-2 Reports, Washington, D.C.
Medicare Hospital Manual, U.S. Dept. of Health and Human Services, HCFA - Pub. 10 thru T703, Rev. 7/97. Billing Procedures Section 437.
National Correct Coding Policy Manual for Part B Carriers, Third Edition, 1997. U.S. Dept. of Commerce.
U.S. Department of Justice, Subpoena dated December 27, 1996 (exhibit A regarding: Outpatient Laboratory Billings To Medicare and Medicaid Programs)
Audit Sheet Instructions: Hematology
Policy Reference Number: BOS.LAB.002
Select a random sample of outpatient accounts as described in the Random Sampling Instructions (Attachment B - Audit & Monitoring Policy BOS.GEN.001).
Obtain the following documents for each patient account selected and perform the self-audit function.
- The documentation/forms such, as the Lab Requisition form, Encounter form, Physician Order form, etc. which is used to document orders.
- Detail Bill and UB 92 generated from the Accounts Receivable System.
- Billing documents generated from the Electronic Billing System.
- Remittance Advice and/or billing details from the applicable Medicare On-line system.
The Billing documents from the A/R system, Electronic Billing System and Remittance Advice and/or Medicare On-line system need to be utilized to complete the Audit Worksheet to help ensure the following:
(Note: If corrections were not made to the accounts receivable system, it is not applicable to compare documents from A/R system to actual billing documents.)
- Review of the billing documents from the A/R system will help identify and address underlying process and / or masterfile/dictionary issues in the Order Entry, Laboratory or A/R systems to the fullest extent possible within system limitations. For those instances in which the current Order Entry, Laboratory or A/R systems will not produce a compliant bill, Electronic Billing System edits will be established to edit the claims and provide a tool to make appropriate corrections.
- Electronic Billing system edits will be properly established in accordance with the applicable billing policies and corrections to billing data made in both the Electronic Billing system and the Accounts Receivable system. This will help ensure a compliant bill is properly submitted as well as proper updates to the A/R systems to ensure accurate A/R valuation, logs, patient statements, billings to secondary payors, etc.
- Detail billing data on the Remittance Advice and/or billing details from the Medicare On-line system will be reviewed to ensure inappropriate changes were not made to the claim on the Medicare On-line system.
Complete each field on the Audit Worksheet as follows:
Complete (A) - (W) using the UB92 and Detail Bill from the A/R system and ordering documentation as necessary.(A) - (C) / Complete the Account #, Patient Name, Financial Class, and Date of Service fields for the federally funded payors.
(D) / If more than 2 components are charged per Date of Service, indicate “Y” (yes). If 2 or less components are charged, indicated “N” (no).
(E) - (L) / If (D) was answered “Y” indicating more than 2 Hematology procedures per Date of Service, indicate the number of instances each applicable CPT code was charged. Document specific issues including underlying process and/or masterfile/dictionary issues in the Comments Column.
(M) / If more than one hematology profile was present per Date of Service, indicate “Y” (yes). If only one hematology was present, indicate “N” (no).
(N) - (T) / If (M) was answered “Y” (yes), indicated more than one hematology profile was charged per Date of Service, indicate the number of instances each applicable CPT code was charged. Document specific issues including underlying process and/or masterfile/dictionary issues in the Comments Column.
(U) / If both a component and a profile are charged per Date of Service, indicate “Y” (yes). If not, indicate “N” (no). The following components should be bundled as listed below:
(N) / (O) / (P) / (Q) / (R) / (S) / (T)
85021 / 85022 / 85023 / 85024 / 85025 / 85027 / 85031
85007 / 85007 / 85007 / 85007 / 85007
85009 / 85009 / 85009 / 85009 / 85009 / 85009
85013/85014 / 85013/85014 / 85013/85014 / 85013/85014 / 85013/85014 / 85013/85014 / 85013/85014
85018 / 85018 / 85018 / 85018 / 85018 / 85018 / 85018
85041 / 85041 / 85041 / 85041 / 85041 / 85041 / 85041
85048 / 85048 / 85048 / 85048 / 85048 / 85048 / 85048
85595 / 85595 / 85595 / 85595 / 85595
The Profile CPT Codes are defined as follows:
85021 / Hemogram, automated (RBC, WBC, Hgb, Hct, and indices only)
85022 / Hemogram, automated, and manual differential WBC count (CBC)
85023 / Hemogram and platelet count, automated, and manual differential WBC count (CBC)
85024 / Hemogram and platelet count, automated, and automated partial differential WBC count (CBC)
85025 / Hemogram and platelet count, automated, and automated complete differential WBC count (CBC)
85027 / Hemogram and platelet count, automated
85031 / Blood count; hemogram, manual, complete CBC (RBC, WBC, Hgb, Hct, differential and indices)
(V) / If any CPTs present on the account were billed with a Revenue Code other than 30X, indicate "Y" (yes). If all CPTs present on the account were billed with 30X indicate "N" (no).
(W) / If (V) was answered "Y" indicating CPT(s) were present on the account with a Revenue Code other than 30X, enter the applicable procedure code/billing code #, CPT and Revenue Code for the procedure. Document specific issues including underlying process and/or masterfile/dictionary issues in the Comments Column.
Complete (X) - (Z) using the billing documentsfrom the EP Vendor, RA and/or On-line Medicare system and ordering documentation as necessary.
(X) / Review the billing documents from the EP Billing Vendor and determine if the actual bill submitted was in accordance with policy after edits/translations were performed on the bill from the A/R system. If the submitted bill was not in accordance with policy indicate "Y" (yes). If the submitted bill was in accordance with policy indicate "N" (no). Document specific issues including underlying process and/or masterfile/dictionary issues in the Comments Column.
(Y) / If applicable, compare the billing documents from the EP Billing Vendor system to the Detail Bill and the UB 92 from the A/R System and determine if all edits performed on the EP Vendor were corrected in the A/R system. If corrections were not made on the A/R system, indicate “Y” (yes). If corrections were made on the A/R system, indicate “N” (no). Document specific issues including underlying process and/or masterfile/dictionary issues in the Comments Column.
(Z) / Compare the billing documents from the EP Billing Vendor system to the Medicare On-line system or the Remittance Advice to determine if any inappropriate changes were made to the claim on the Medicare On-line system. If variances exist indicate “Y” (yes). If variances do not exist indicate “N” (no).
(AA) / Enter specific comments related to special circumstances or exceptions with each account. Attach an additional sheets as necessary.
(AB) / Enter the total number of applicable accounts reviewed (e.g. exclude the N/As).
(AC) / Enter the total number of accounts for which (X) - (Z) was answered "Y".
(AD) / Calculate the % Error Rate by dividing (AC) by (AB).
Log the overall error rates, issues and actions to be taken on the Laboratory Action Worksheet in accordance with the “Billing - Auditing Procedures” Policy, Reference # BOS.GEN.001.
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