PAGE: 1 of 4 / REPLACES POLICY DATED:1/16/98, 3/1/99, 8/1/02, 2/15/03 (GOS.LAB.002); 3/6/06; 1/1/07; 5/1/08; 8/1/08; 11/1/11
EFFECTIVE D ATE: January 1, 2013 / REFERENCE NUMBER: REGS.LAB.002
APPROVED BY: Ethics and Compliance Policy Committee
SCOPE: All Company-affiliated facilities performing and/or billing laboratory services. Specifically, the following departments:
Business Office Non-physician Practitioners (NPP)
Admitting/Registration Laboratory
Finance Medical Staff
Administration Shared Services Centers
Revenue Integrity
PURPOSE: To establish guidelines for billing hematology services in accordance with Medicare, Medicaid, and other federally-funded payer requirements.
POLICY: Hematology tests billed to a federally-funded program must be based on a documented physician or non-physician practitioner (NPP)order and be medically necessary. Hematology components will be bundled to the panel level when all of the tests in the panel are ordered and performed. Hematology tests which include all components of a panel must not be “unbundled” into individual procedures.
Repeated hematology procedures, including overlapping components of panels, may be billed when the tests are medically necessary, which is indicated by reporting modifier 91. Modifier 91 may only be reported when in the course of treating a patient, it is necessary to repeat the same laboratory test on the same day to obtain subsequent test results. This modifier may not be reported when tests are rerun to confirm initial results; due to testing problems with specimens or equipment; or for any other reason when a normal, one-time, reportable result is all that is required. This modifier may not be used when other code(s) describe a series of test results (e.g., glucose tolerance tests, evocative/suppression testing). If a payer does not recognize or accept modifier 91 and the payer has not provided you with their specific billing guidance for repeated laboratory tests, these tests may not be billed.
PROCEDURE: The following steps must be performed when billing hematology services to Medicare and other federally-funded programs. Except as defined in REGS.LAB.007 “Custom Profiles,” REGS.LAB.009 “Referred Laboratory Testing,” and REGS.GEN.004 “Orders for Outpatient Tests and Services,” protocols should not be utilized for laboratory tests.
IMPLEMENTATION
- Facility personnel must review and verify applicable entries are present in the facility chargemaster and appropriately tied to the related Laboratory and Order Entry masterfiles/dictionaries as follows:
- Assign CPT /HCPCS codes listed below and attach revenue code 305 in accordance with the Company Standard Laboratory Chargemaster.
CPT Code AMA Description
85004 Blood count; automated differential WBC count
85013 Blood count; spun microhematocrit
85014 Blood count; hematocrit (Hct)
85018 Blood count; hemoglobin (Hgb)
85041 Blood count; red blood cell (RBC) , automated
85048 Blood count; leukocyte (WBC), automated
85049 Blood count; platelet, automated
Hematology Panels:
CPT/HCPC Code AMA Description
85025 Blood count; complete (CBC), automated (Hgb, Hct, RBC, WBC and platelet count) and automated differential WBC count
85027 Blood count; complete (CBC), automated (Hgb, Hct, RBC, WBC and platelet count)
G0306 Complete CBC, automated (HgB, Hct, RBC, WBC, without platelet count) and automated WBC differential count
G0307 Complete CBC, automated (HgB, Hct, RBC, WBC; without platelet count)
- When all components of a panel are present, the componentsmust be bundled to the appropriate panel. Fewer components may be ordered as a “panel” but must be billed as individual components, e.g., H & H (Hemoglobin and Hematocrit).
- Laboratory and Shared Services Center personnel must educate all staff associates responsible for ordering, charging, or billing laboratory services on the contents of this policy.
- Monitoring activities should be completed in accordance with the Billing – Monitoring Policy, REGS.GEN.001.
- It is recommended but not required that laboratory personnel review daily charge reports (e.g., Ancillary Charge Report, NPR charge reports, etc.) to verify compliance with this policy as follows:
- Duplicate hematology components which are not medically necessary are not billed to federally-funded programs.
- Repeated hematology panels and components are billed to federally-funded programs only when medically necessary.
- Hematology components are bundled to the appropriate panel defined as follows:
85004 85004
85013(14) 85013(14) 85013(14) 85013(14)
85018 85018 85018 85018
85041 85041 85041 85041
85048 85048 85048 85048
85049 85049
- Shared Services Center personnel must review electronic billing edit/error reports daily and perform the following:
b.Identify presence of more than one hematology panel and determine if documentation is present to support medical necessity of repeated panels.
i.Append modifier 91 to repeated hematology procedures which are medically necessary.
ii.Eliminate repeated tests/panels which are not medically necessary. 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.
The Facility Ethics and Compliance Committee is responsible for implementation of this policy within the facility.
Special Considerations:
DO NOT CHARGE FOR services reported as a result of a calculation.
DO NOT CHARGE FOR both manual and automated differential on the same patient for the same date of service. Medicare considers the reflex to the manual differential as part of the steps necessary to complete the physician's order. It would not be appropriate to bill for the reflex test even if your instrument flags the test and you also perform a manual differential. If, however, a CBC is ordered and CPT code 85027 is billed, per the below, a manual differential may be billed if the reflex test complies with the REGS.LAB.010 – Reflex Tests. For additional information regarding reflex tests refer to REGS. LAB.010 – Reflex Tests.
Calculated test results: It is not appropriate to bill for a laboratory test result that is derived by calculation from an underlying laboratory test. Therefore, these tests are excluded from the Company Standard Laboratory Chargemaster. The only exception is the automated hematocrit. This test is derived by calculation from one measured, separately billable test (RBC), and one non-billable, calculated test (Mean Corpuscular Volume). CMS and other entities have ruled that this test is separately billable.
REFERENCES:
- AMA CPT Assistant, July 2003 Page: 7, Category: Coding Communication
- American Medical Association Physician’s Current Procedural Terminology CPT
- American Medical Association’s CPT Changes 2003 – An Insider’s View
- Billing -Orders for Hospital Outpatient Tests and Services Policy, REGS.GEN.004
- BILLING - Custom Profiles Policy, REGS.LAB.007
- BILLING - Referred Laboratory Testing Policy, REGS.LAB.009
- LABORATORY - Reflex Tests Policy, REGS.LAB.010
12/2012
12/2012