January 2017

Richard Cooley, BA, CCS RCooley@EpochHealth.comJean C. Russell, MS, RHIT JRussell@EpochHealth.com

Matthew H. Lawney, MSPT, MBA, CHC MLawney@EpochHealth.com518-430-1144

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Agenda Changes 2017

L1 Modifier New Fee Schedule 2018 Drug Assays New Proprietary Tests

CLIA Waived Lab Payment History and Present

Split Billing

Crunching Numbers Compliance Denial Management Modifiers

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2017 Lab Changes

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Invalid Labs for 2017HCPCS Code Short Descriptor CI 2017 FR SI

80100 Drug screen qualitate/multi CH  D

80300 Drug screen non tlc devices CH  D

80301 Drug screen class list a CH  D

80302 Drug screen prsmptv 1 class CH  D

80303 Drug screen one/mult class CH  D

80304 Drug screen one/mult class CH  D

81280 Long qt synd gene full seq CH  D

81281 Long qt synd known fam var CH  D

81282 Long qt syn gene dup/dlt var CH  D

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New Lab Codes for 2017

HCPCS Code Short Descriptor CI 2017 FR SI80305 Drug test prsmv dir opt obs NC Q480306 Drug test prsmv instrmnt NC Q480307 Drug test prsmv chem anlyzr NC Q481327 Sept9 methylation analysis NC A81413 Car ion chnnlpath inc 10 gns NC A81414 Car ion chnnlpath inc 2 gns NC A81422 Fetal chrmoml microdeltj NC A81439 Inherited cardmypthy 5 gns NC A81539 Oncology prostate prob score NC Q484410 Testosterone bioavailable NC Q487483 Cns dna amp probe type 12‐25 NC Q4

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Mapping to New CodesCPT Short Description

2017 SI Mapping to 2017 codes

80100Drug Screen Qual Mult Chromatography D Invalid 12/31/2016‐ to report see 80305‐80307

80300 Drug screen non tlc devices D Invalid 12/31/2016 ‐to report see 80305, 80306

80301 Drug screen class list a D Invalid 12/31/2016 ‐to report use 80307

80302 Drug screen prsmptv 1 class D Invalid 12/31/2016 ‐to report use 80307

80303 Drug screen one/mult class D Invalid 12/31/2016 ‐to report use 80307

80304 Drug screen one/mult class D Invalid 12/31/2016 ‐to report use 80307

81280 Long QT Synd Gene Full Seq D Invalid 12/31/2016 ‐to report use 81413

81281 Long QT Synd Known Fam Var D Invalid 12/31/2016 ‐to report use 81413

81282 Long QT Syn Gene Dup/Dlt Var D Invalid 12/31/2016 ‐to report use 81414

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Add ADLTs to Status A List Currently excluded from the laboratory packaging policy

are the molecular pathology studies 81161 through 81383, 81400 through 81408, and

81479 Assign status indicator “A” (Separate payment under the

CLFS) to advanced diagnostic laboratory tests(ADLTs) once a laboratory test is designated an ADLT under the CLFS – OPPS 2017 FR

ADLTs: tests that provide an analysis of multiple biomarkers of DNA, RNA, or proteins combined with a unique algorithm to yield a single patient-specific result

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L1 Modifier Cancelled due to Lack of Interest

Multiple hospitals have informed us that the “unrelated” laboratory test exception is not useful to them because they cannot determine when a laboratory test has been ordered by a different physician and for a different diagnosis.

OPPS 2017 FR

L1 for “unrelated” laboratory test exception discontinued 1/1/2017

Will package any and all laboratory tests (except molecular pathology tests, certain ADLTs, and preventive tests) if they appear on a claim with other hospital outpatient services.

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Hepatitis B Screening New HCPCS code, G0499, Hepatitis b screening in

non-pregnant, high risk individual includes hepatitis b surface antigen (hbsag) followed by a neutralizing confirmatory test for initially reactive results, and antibodies to hbsag (anti-hbs) and hepatitis b core antigen (anti-hbc)

Effective 9/28/2016, APC SI A See Chapter 1, Medicare NCD Manual, Section

210.10 for more information

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New Lab Rates Laboratories will collect private payer data from

January 1, 2016 through June 30, 2016 and report it to CMS by March 31, 2017

CMS will post the new Medicare CLFS rates (based on weighted median private payer rates) in November 2017 that will be effective on January 1, 2018

Under the new CLFS, there will be no geographic adjustments to the payment amount

MLN Matters article-https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/Downloads/SE1619.pdf

https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/ClinicalLabFeeSched/PAMA-Regulations.html

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Lab Data Collection 2017 CLFS FR (6/23/2016) covers data

collection and reporting requirements Under Protecting Access to Medicare Act of 2014

(“PAMA”) current lab fees will replaced with new fees based on data collected from private payer rates

Applicable laboratories will be required to collect data from different date ranges and report to Medicare

https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/ClinicalLabFeeSched/PAMA-Regulations.html

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Data Collection Applicable laboratories, including physician office

laboratories, are required to report if they: Are certified under CLIA Bill Medicare Part B under its own laboratory NPI Have more than $12,500 in Medicare revenues from laboratory

services on the CLFS and They receive more than 50 percent of their Medicare revenues

from laboratory and physician services during a data collection period.

Unlikely that hospital-based labs, which bill under Hospital NPI (not lab NPI), will qualify as applicable lab, though some hospital “outreach” labs may

https://www.cms.gov/Newsroom/MediaReleaseDatabase/Fact-sheets/2016-Fact-sheets-items/2016-06-17.html

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Drugs of Abuse

14 2016 Drugs of Abuse Late Changes

Drugs of Abuse reporting use new G-codes First published in the CLFS, not in the Final Rule

Addendum B or RVU table!

G0431Valid through 12/31/2015‐ to report see Presumptive ID Codes G0477‐G0479 (method specific)

G0434Valid through 12/31/2015‐ to report see Presumptive ID Codes G0477‐G0479 (method specific)

G6030 through G6058Valid through 12/31/2015‐ to report see Definitive ID Codes G0480‐G0483 (drug class units specific)

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2017 New Drugs of Abuse Codes CLFS Final Rule: Presumptive ID replaced with

8030x

G0477-G0479 will be replaced with 80305-80307, though not correct in the Addendum B

https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/ClinicalLabFeeSched/Downloads/CY2017-CLFS-Codes-Final-Determinations.pdf

2016‐2017? New for 2017HCPCS Short description SI CPT Short description SIG0477 Drug test presump optical D 80305 Drug test prsmv dir opt obs Q4G0478 Drug test presump opt inst D 80306 Drug test prsmv instrmnt Q4G0479 Drug test presump not opt D 80307 Drug test prsmv chem anlyzr Q4

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Definitive ID Drugs of Abuse Review new code G0659

2016 New for 2017

HCPCS Short description SI CPT Short description SI

G0480 Drug test def 1‐7 classes Q4

G0481 Drug test def 8‐14 classes Q4

G0482 Drug test def 15‐21 classes Q4

G0483 Drug test def 22+ classes Q4

G0659Drug Test Definitive Simple any number Classes ?

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Review Long Descriptions Description change for Drugs of Abuse G-codes

https://www.cms.gov/Medicare/Coding/HCPCSReleaseCodeSets/Alpha-Numeric-HCPCS-Items/2017-Corrections-to-Alpha-Numeric-HCPCS-File.html?DLPage=1&DLEntries=10&DLSort=0&DLSortDir=descending

G0659

Drug test(s), definitive, utilizing drug identification methods able to identify individual drugs and distinguish between structural isomers (but not necessarily stereoisomers), including but not limited to GC/MS (any type, single or tandem) and LC/MS (any type, single or tandem), excluding immunoassays (e.g., IA, EIA, ELISA, EMIT, FPIA) and enzymatic methods (e.g., alcohol dehydrogenase), performed without method or drug‐specific calibration, without matrix‐matched quality control material, or without use of stable isotope or other universally recognized internal standard(s) for each drug, drug metabolite or drug class per specimen; qualitative or quantitative, all sources, includes specimen validity testing, per day, any number of drug classes

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MUE and CCI All the screening and confirmation codes (80305-

80307, G0480-G0483) have a Medically Unlikely Edit of 1

Either defined as “Any number of drug classes… Per Date of Service” or specific number of drugs classes

Only one code from range 80305-80307 and one code from range G0480-G0483 may be reported per day (per NCCI policy manual chapter 10)

Note a code from each (screening and confirmation) may be reported together on the same DOS- no CCI edit! There was confusion with this in 2016

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Do Not Bill for Validity Test From the NCCI Lab Manual0 Chapter 10 Providers performing validity testing on urine

specimens utilized for drug testing should not separately bill the validity testing. For example, if a laboratory performs a urinary pH, specific gravity, creatinine, nitrates, oxidants, or other tests to confirm that a urine specimen is not adulterated, this testing is not separately billed.

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Proprietary Lab Analysis

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Proprietary Lab Analysis CPT® Editorial Panel approved creation of new PLA

section in CPT These are mostly molecular pathology codes PLA CPT codes are available to any clinical lab or

manufacturer that wants to specifically identify their lab test (e.g., “Mannington Lab Tumor Analysis”)

Applications will be accepted beginning in 2017

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Proprietary Lab Analysis New codes will be approved quarterly and effective the

following quarter The new codes will be published on:

amaproductupdates.org The codes will be published in the next CPT® book When a new code becomes available to report a

particular test, then that code should be used rather than another code

AMA expects ~ 500 applications in the first round Present in section xvi of the CPT® Professional 2017

book

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Three Approved There are currently three PLA codes that have been

approved by the AMA: 0001U – Red blood cell antigen typing, DNA, human erythrocyte

antigen gene analysis of 35 antigens from 11 blood groups, utilizing whole blood, common RBC alleles reported;

0002U – Oncology (colorectal), quantitative assessment of three urine metabolites (ascorbic acid, succinic acid and carnitine) by liquid chromatography with tandem mass spectrometry (LC-MS/MS) using multiple reaction monitoring acquisition, algorithm reported as likelihood of adenomatous polyps;

0003U – Oncology (ovarian) biochemical assays of five proteins (apolipoprotein A-1, CA 125 II, follicle stimulating hormone, human epididymis protein 4, transferrin), utilizing serum, algorithm reported as a likelihood score

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Waived TestsQW Modifier

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Lab Testing Certificates The Clinical Laboratory Improvement Amendments

(CLIA) of 1988 requires all laboratory testing sites to have one of the following certificates to legally perform clinical laboratory testing:

Certificate of Waiver Certificate of Registration Certificate of Accreditation Certificate for Physician-Performed Microscopy

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Certificate of Waiver Tests Laboratories within a hospital that are located at

contiguous buildings on the same campus and under common direction may file a single application for the laboratory sites within the same physical location or street address.

Certificate of Waiver Issued to a laboratory that performs only waived tests.

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Waived Tests Defined by CLIA, waived tests are categorized as

“simple laboratory examinations and procedures that have an insignificant risk of an erroneous result”. The Food and Drug Administration (FDA) determines the criteria for tests being simple with a low risk of error and approves manufacturer’s applications for test system waiver.

https://ftp.cdc.gov/pub/CLIAC_meeting_presentations/pdf/Addenda/cliac1115/12_Tobin_Peter_WaiverGuidance_CLIAC_.pdf

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2017 CLIA Waived Tests 2017 CLIA waived list QW modifier on Clinical Lab Fee Schedule Some CLIA waived tests do not require QW modifier

CPT Short Description SI81002 Urinalysis nonauto w/o scope Q481025 Urine pregnancy test Q482270 Occult blood feces A82272 Occult bld feces 1‐3 tests Q482962 Glucose blood test Q483026 Hemoglobin copper sulfate Q484830 Ovulation tests Q485013 Spun microhematocrit Q485651 Rbc sed rate nonautomated Q4

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Approved Kits Some examples:

87631QW, July 25, 2016 Roche Molecular, cobas Liat System cobas Liat Influenza A/B & RSV Assay;

G0477QW, July 28, 2016, Germaine Laboratories, Inc., AimScreen Multi-Drug Urine Test DipDevice;

Complete list of new kits:https://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/2016-Transmittals-Items/R3666CP.html

Complete list of approved kits:https://www.cms.gov/Regulations-and-Guidance/Legislation/CLIA/downloads/waivetbl.pdf

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CLIA Edit 2017 list of codes subject to CLIA Edits Tests that can not be performed under a

CLIA certificate of waiver: https://www.cms.gov/regulations-and-

guidance/legislation/clia/downloads/subjecttoclia.pdf

If a service is denied as not covered under your CLIA certificate, you may not bill the beneficiary for the service

http://www.wpsmedicare.com/j8macpartb/resources/modifiers/qwmodifier.shtml

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Reporting QW modifier? Laboratories with a CLIA certificate of waiver may

perform only those tests cleared by the Food and Drug Administration (FDA) as waived tests. Laboratories with a CLIA certificate of waiver shall bill using the QW modifier.

Laboratories with a CLIA certificate of compliance or accreditation may perform non-waived tests. Laboratories with a CLIA certificate of compliance or accreditation do not append the QW modifier to claim lines.

https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/downloads/SE1105.pdf

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Payment Basics

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Payment NostalgiaMedicareLaboratory for 2000-2013Medicare Status A are paid on the

Medicare Clinical Laboratory Fee Schedule (CLFS)

Paid lesser of hospital charge or CLFS fee Run report where charges are less than fee

Not subject to deductible or coinsurance

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2014 Clinical Lab PackagingCMS packaged all clinical lab tests 1086 clinical lab codes are were packaged

Became packaged on a type-of-bill (TOB) 131 whether they are “integral, ancillary, supportive, dependent or adjunctive to a primary service”

An exception created for “lab only” visits

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7/1/2014 – 12/31/2015 Bill on a type-of-bill (TOB) 141 – referred lab test

For patients that are “neither an inpatient nor an outpatient of a hospital, but that has a specimen that is submitted for analysis to a hospital and the beneficiary is not physically present at the hospital” Specimen collected elsewhere

Report L1 modifier Outpatient lab tests only – “If the hospital only provides outpatient

laboratory tests to the patient and the patient does not also receive other hospital outpatient services on that day… report on TOB 13X with modifier L1” Specimen collected by Hospital

Medicare Claims Processing Manual Chapter 16 - Laboratory Services, Section 30.3

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2016 L1 Modifier For CY 2016 lab tests are conditionally packaged

(Q4), regardless of the date of service, on claims with SI J1, J2, S, T, V, Q1, Q2, or Q3 unless “unrelated” to the other HOPD service or services on the claim (L1)

New SI “Q4” for this purpose When laboratory tests are the only services on the

claim, a separate payment at CLFS payment rates will be made L1 is not required in these instances and should not be

reported

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Q4 Status Indicator TOB 141 specimen received from outside source-

patient not physically present Paid on Clinical Lab Fee Schedule

TOB 131 reported with status indicator Q4 only on claim will be paid under fee schedule, otherwise packaged OCE will covert Q4 to A and be paid on Fee Schedule

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MLFS LocalityCarrier Locality Lab Location

13282 99 NY1 REST OF NEW YORK

13202 1 NY2 MANHATTAN, NY

13202 2 NY2 NYC SUBURBS/LONG I., NY

13202 3 NY2POUGHKPSIE/N NYC SUBURBS, NY

13292 4 NY3 QUEENS, NY

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Revenue Codes Revenue codes– per Ingenix Uniform Billing Editor

(UBE) 30x– Clinical Laboratory 31x– Pathology 390– Blood processing and storage 391– Blood administration 636– Drugs requiring detailed coding

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Medicare Inpatient (IP) Payment Medicare IP

Pays under Inpatient Prospective Payment System (IPPS)

One DRG (Diagnostic Related Group) is assigned per hospital inpatient stay

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IPPSDRG level not impacted by lab studies or blood products– in other words, labs are covered under DRG payment Some facilities are exempt from IPPS

(e.g., designated cancer centers, children’s hospitals, CAHs)

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Medicaid Medicaid APGs OP Visits Labs are billed under the appropriate rate code;

e.g., clinic (1432), ED (1402) Covered under APG payment

“Ordered Ambulatory” tests not associated with clinic visit Ordered Ambulatory referred by outside physician–

covered under Medicaid ambulatory fee schedule-patient not present

Will bill separately (non-APG) no rate code

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APG Payment Hierarchy Significant Procedures: A procedure/service which

constitutes the reason for the visit and dominates the time and resources expended during the visit Payment based on HCPCS code

Medical Visits: A visit during which a patient receives medical treatment but does not have a significant procedure performed Payment based on the primary diagnosis

Ancillary Tests and Procedures: A test or procedure to assist in patient diagnosis or treatment Ancillary service APG assigned in the absence of Significant

Procedure or Medical Visit Payment (if paid) based on HCPCS code

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Ancillary Billing Policy Payment for laboratory and radiology

services ordered by practitioners in hospital based outpatient clinics is made to the clinic

The ancillary service provider may not bill Medicaid directly for lab or the technical component of radiology services related to an APG reimbursed visit

Therefore must bill the ordering clinic for the service provided to clinic patients

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Episode of Care Episode of care consists of a medical visit and/or

significant procedure that occurred on a single date of service and all the associated ancillary services that occurred on or after the date of the medical visit or significant procedure

All procedure codes related to an episode of care should be reported on a single claim

Claim must include a “from” and “to” date in the claim header to reflect the episode of care

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Carve-Outs Found in the “never pay” files Combine Never pay APGs and Never pay

Procedures Remove “No alternative payment available”

2015 ~ 83 lab carve out codes 2016 ~ 200 lab carve out codes July 2016 ~ 208 lab carve out codesMedicaid has not updated never pay list for

1/2017https://www.health.ny.gov/health_care/medicaid/rates/methodology/

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Split Billing for Lab Services Clinical diagnostic laboratory services are paid on

the CLFS, not under OPPS Some lab services are paid under APCs, e.g.,

surgical pathology Typically fee schedule will be technical only whereas

APC paid labs may be split Medicare will pay for professional and technical

components NYS Medicaid will pay one fee that covers both

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Identifying Professional Lab RVU Status “A” on the RVU table A = Active Code. These codes are paid

separately under the physician fee schedule, if covered. There will be RVUs for codes with this status

Payment in the Carrier fees file

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What Can be Split? PC/TC 0 = Physician Service Codes--Identifies codes that describe physician

services. Examples include visits, consultations, and surgical procedures. Non-QW codes could be split QW codes are reported on 1500 for free standing CLIA waived offices

1 = Diagnostic Tests for Radiology Services--Identifies codes that describe diagnostic tests. Examples are pulmonary function tests or therapeutic radiology procedures, e.g., radiation therapy. These codes have both a professional and technical component

2 = Professional Component Only Codes--This indicator identifies stand-alone codes that describe the physician work

6 = Laboratory Physician Interpretation Codes--This indicator identifies clinical laboratory codes for which separate payment for interpretations by laboratory physicians may be made. Actual performance of the tests is paid for under the lab fee schedule

8= Physician interpretation codes: This indicator identifies the professional component of clinical laboratory codes

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Travel Allowance Per Mile Travel Allowance (P9603) Flat Rate (P9604) – used for less than 10 miles of

travel The claimant identifies round trip travel by use of the

LR modifier

Transmittal 3189 Date: February 5, 2015 Change Request 9066; https://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/Downloads/R3189CP.pdf

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Crunching Numbers

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Medicare 1966: Start of Medicare Program 2006-2013: Part A Fiscal Intermediaries (FI) and Part

B carriers became Medicare Administrative Contractors (MACs) Intended to improve Medicare's administrative

services including competition and performance incentives

A network of 16 MACs Process Medicare claims The MACs process nearly 4.9 million Medicare

claims each business day and disburse more than $365 billion annually in program payments

https://www.gpo.gov/fdsys/pkg/FR-2015-12-21/html/2015-32027.htm

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Payment Impact for 2017Yearly Budget ImpactFew Insurance payment $ in laboratory

cost center Will need to compensate for budgeting

CDM support software may have reports Craneware CodeCorrect/ MedAssets Vital Ware

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Top Lab Increases/ Decreases for 2017

Almost all lab tests are packaged or conditionally packaged (N, Q1, Q2, Q4) (technically) for 2016

No technical reimbursement unless billed on TOB 141, or TOB 131 with SI Q1, Q2, Q4 and not packaged

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CLFS Small Increase

Minor increases overall- 70% of codes increase less than 1%No decreases in CLFS for 2017

HCPCS Short Description2017 Status Indicator

Oct 2016 NY1 Jan 2017 NY1 $ Increase %

G0483 Drug test def 22+ classes Q4 215.23 253.87 38.64 15.22%G0482 Drug test def 15‐21 classes Q4 166.03 204.34 38.31 18.75%G0481 Drug test def 8‐14 classes Q4 122.99 160.99 38.00 23.60%G0480 Drug test def 1‐7 classes Q4 79.94 117.65 37.71 32.05%81219 Calr gene com variants A 110.99 166.84 55.85 33.48%81273 Kit gene analys d816 variant A 72.15 125.74 53.59 42.62%81528 Oncology colorectal scr A 262.84 500.04 237.20 47.44%81170 Abl1 gene A 115.21 331.82 216.61 65.28%81218 Cebpa gene full sequence A 115.21 331.82 216.61 65.28%81272 Kit gene targeted seq analys A 115.21 331.82 216.61 65.28%

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Professional Lab RVU Status “A” on the RVU table

A = Active Code. These codes are paid separately under the physician fee schedule, if covered. There will be RVUs for codes with this status.

66% had an increase of less than 1% on PFS for 2017 (mod=26, rvu si=A”

.pdf read-me file included with the RVU table

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Top PFS Increases

HCPCS Mod Short Description

RVU stat

Carrier 13282 Locality 99 POS 19/22

Carrier 13282 Locality 99 POS 19/22 10/2016 diff %

88373 26M/phmtrc alys ishquant/semiq A $28.20 $21.08 $7.12 25.25%

88341 26 Immunohisto antibody slide A $29.19 $27.37 $1.82 6.24%88350 26 Immunofluor antb addl stain A $29.58 $28.10 $1.48 5.00%88369 26 M/phmtrc alysishquant/semiq A $32.85 $31.37 $1.48 4.51%88364 26 Insitu hybridization (fish) A $35.82 $34.35 $1.47 4.10%88358 26 Analysis tumor A $46.83 $45.39 $1.44 3.07%88304 26 Tissue exam by pathologist A $11.88 $11.53 $0.35 2.95%88182 26 Cell marker study A $38.08 $36.98 $1.10 2.89%88368 26 Insitu hybridization manual A $41.69 $40.58 $1.11 2.66%88381 26 Microdissection manual A $25.73 $25.34 $0.39 1.52%

88360 26Tumor immunohistochem/manual A $56.30 $55.49 $0.81 1.44%

88362 26 Nerve teasing preparations A $112.00 $110.46 $1.54 1.38%

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Largest PFS Decreases

HCPCS Mod Short Description

RVU stat

Carrier 13282 Locality 99 POS 19/22

Carrier 13282 Locality 99 POS 19/22 10/2016 diff %

88387 26 Tiss exam molecular study A $30.56 $32.56 ‐$2.00 ‐6.54%88125 26 Forensic cytopathology A $12.98 $13.58 ‐$0.60 ‐4.62%88380 26 Microdissection laser A $56.37 $57.54 ‐$1.17 ‐2.08%88319 26 Enzyme histochemistry A $27.43 $27.71 ‐$0.28 ‐1.02%

88162 26Cytopath smear other source A $40.01 $40.27 ‐$0.26 ‐0.65%

88346 26 Immunofluorescent study A $37.35 $37.53 ‐$0.18 ‐0.48%88300 26 Surgical path gross A $4.48 $4.49 ‐$0.01 ‐0.22%88302 26 Tissue exam by pathologist A $7.29 $7.30 ‐$0.01 ‐0.14%

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Cost Center ImpactOutpatient Revenue by Rev Code(based on charges)

Dept Sum Charges Revenue codesPercent of charges

Radiology $865,387,583.31 32x,33x,34x,35x,40x,61x 27%Laboratory $597,534,308.22 30x,31x,39x 18%Surg/treat $563,974,920.56 36x,49x,75x,76x 17%Pharmacy $275,423,132.66 25x,63x 9%Clinic $187,565,145.47 51x 6%Supplies $184,253,430.67 27x,62x 6%Cardiology $163,574,163.94 48x 5%ED $158,385,228.70 45x 5%PT, OT, SP, Audio $86,601,517.95 42x,43,44x,47x 3%Psych $68,700,757.68 90x,91x 2%EEG, EKG $48,542,058.96 73x,74x 2%Pulm, resp $20,601,454.81 41x,46x 1%IV Therapy $12,403,930.75 26x 0%Oncology $1,047,887.23 28x 0%Miscellaneous $226,542,222.03 7%

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Cost Center ChartPercent of charges Radiology

LaboratorySurg/treatPharmacyClinicSuppliesCardiologyEDPT, OT, SP, AudioPsychEEG, EKGPulm, respIV Therapy

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Top Lab HCPCS by CountHCPCS Description Sum Count

85025 Comp Bld Cnt Auto/ Auto Diff 543,226

36415 Venipuncture 522,800

80053 Comprehensive Metabolic Panel 356,943

85610 Prothrombin Time 293,155

80048 Basic Metabolic Panel 267,350

85730 PTT/ APTT 197,130

88305 Surg Path Level IV 158,586

85027 Comp Bld Cnt Auto/ wo Diff 132,546

84484 Troponin Quant 116,342

82550 Creatine Kinase CK (CPK) Tot 102,229

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Average Charge Mark-upHCPCS Desc

MLFS NY1/ APC

Average charge-National % mark-up

80053 Comprehensive Metabolic Panel $14.53 $150 1032%88305 Surg Path Level IV $38.10 $220 577%85025 Comp Bld Cnt Auto/ Auto Diff $10.69 $75 702%80048 Basic Metabolic Panel Ca Tot $11.63 $115 989%36430 Transfusion Blood/Components $260.44 $700 269%84484 Troponin Quant $13.53 $125 924%85610 Prothrombin Time $5.40 $48 889%85730 PTT/ APTT $8.25 $65 788%P9016 RBCs L/R Ea Unit $193.24 $410 212%36415 Venipuncture $3.00 $18 600%

The average markup for lab charges- 554%Recent Peer analysis for six upstate hospitals-mark up- 5.78%

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Compliance

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The Context of Compliance Every claim that is submitted for payment to any

payer has an inherent amount of risk Risk of overpayment by payer Risk of penalties associated with overpayment

If you want zero risk– don’t bill for services Compliance officer/ team determines acceptable

level of risk E.g., Venipuncture is defined as per encounter

Some have interpreted this as per visit Some have interpreted this as per face-to-face encounter with

nurse/phlebotomist

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Compliance in Billing Lab Orders

Treating physician is responsible for determining that a lab test is medically necessary

Hospital is responsible for Showing that the physician was aware of components of

test performed, therefore able to make an informed decision of medical necessity

Collecting and maintaining documentation

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Lab Orders Cont. The physician shall be provided with all the

information about the test (e.g., explosions, potential workups, reference lab details), such that he/she can make an informed decision of medical necessity

The physician should have the option of ordering individual elements of a profile or panel The physician should not have to order a panel of

tests when they only need one element of that panel

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Record that Result was Reviewed

Medicare Claims Processing Manual, Chapter 16 (Laboratory Services), Section 10 (Background) indicates that a laboratory test is a covered benefit only if the test result is utilized for management of the beneficiary’s specific medical problem.

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Billing for Unused Blood Unused or wasted blood

Do not charge the intended beneficiary Hospitals may bill for all related medically necessary

laboratory servicesAutologous collectionFreezing/ thawingTesting (e.g., typing and crossmatch)

What is Billable?ARC

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Freezing and Thawing Bill the P-code that describes the frozen and/or

thawed unit that is transfused Do not bill for the freezing and/or thawing when it is

included (or implied) in the description Freezing and/or thawing may be billed when the unit

is not transfused.

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Blood and Blood Products CMS uses a blood-specific CCR (cost to charge ratio) for

blood payment rates One blood product, P9050, granulocytes, pheresis, each

unit, has no payment due to insufficient claims data (APC SI E2)

Another blood product, P9072, platelets, pheresis, pathogen reduced or rapid bacterial tested, each unit had a description change to include “rapid bacterial testing” Payment for this product has been crosswalked to

P9037, platelets, pheresis, L/R’d, irradiated, each unituntil sufficient claims data becomes available

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2017 Changes to Clotting Factors

HCPCS SVCDESC Mcare SI comments

C9137Factor VIII (antihemophilic factor recombinant) PEGylated Inj 1iu D Invalid 12/31/2016 ‐to report use J7207

C9138Factor VIII (antihemophilic factor recombinant) Nuwiq Inj 1iu D Invalid 12/31/2016 ‐to report use J7209

C9139Factor IX Albumin Fusion Protein (recombinant) Idelvion 1iu D

Valid 10/1/2016 through 12/31/2016 ‐to report use J7202

C9140Factor VIII (antihemophilic Factor recombinant) (afstyla) Inj 1iu G Valid 1/1/2017

J7175 Factor X Inj (human) 1iu K Valid 1/1/2017

J7202Factor IX Albumin Fusion Protein Inj (recombinant) idelvion 1iu G Valid 1/1/2017

J7207Factor VIII Inj (antihemophilic Factor recombinant) pegylated 1iu G Valid 1/1/2017

J7209Factor VIII Inj (antihemophilic Factor recombinant) (nuwiq) 1iu G Valid 1/1/2017

J7179Von Willebrand Factor Inj (recombinant) (vonvendi) 1iu G Valid 1/1/2017

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NCCI Lab Manual See NCCI CHAP10-CPT codes 80000-89999 for

billing limitations Some good information in the manual

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Explosions & Send Outs

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Leveraged Potential for Miscoding

GAMD antibodies-- 82784 x 4 Urine lytes-- 84300, 84133, 84105

Sodium, Potassium, Phospate Many send-outs are explosions- verify routinely

to keep updated

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Send-Outs Coding provided by most reference labs–

Paper Manuals or on-line Make updates at least annually Top 75 tests will cover 70% to 80% of total

volume

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Miscellaneous TestsThe Black Hole that sucks in lab chargesTests that are not in the order menuOften they are reference lab testsThey are charged manually…Or not at all, i.e., written offMonitor volume

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Denial Management

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Coverage Determinations Medical Necessity

The association of HCPCS with required diagnoses is made at both a national and local level National Coverage Determination (NCD) Local Coverage Determination (LCD)

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What is Being Denied?

Status A – fee schedule Account for 84% of the denials by count, and 45% of

the denials by sum charges

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Top Lab Denials# HCPCS description status den units sum den chg % denial

1 84443 ASSAY THYROID STIM HORMONE A 47054 3,354,323.50 10.15%

2 80061 LIPID PANEL A 35800 2,169,809.56 6.57%

3 85610 PROTHROMBIN TIME A 77121 2,033,003.52 6.15%

4 84153 ASSAY OF PSA, TOTAL A 26676 1,974,193.28 5.97%

5 85730 THROMBOPLASTIN TIME, PARTIAL A 47696 1,691,376.35 5.12%

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Leading Reason for DenialsHCPCS Description Denial Reason

Sum Billed Units

Sum Denied Units

Sum Denied Chg

84443ASSAY THYROID STIM

HORMONE NCD 424,055 47,054 $3,354,323

80061 LIPID PANEL NCD 647,830 35,800 $2,169,810

85610 PROTHROMBIN TIME NCD 1,099,038 77,121 $2,033,004

84153 ASSAY OF PSA, TOTAL NCD 130,109 26,676 $1,974,193

85730THROMBOPLASTIN TIME,

PARTIAL NCD 291,860 47,696 $1,691,376

NCD Denial- THE INFORMATION PROVIDED DOES NOT SUPPORT THE NEED FOR THIS SERVICE OR ITEM

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Medical Necessity and ICD-10 Most current list 10/2016:

https://www.cms.gov/Medicare/Coverage/CoverageGenInfo/LabNCDsICD10.html

Example:

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Medical Necessity Denials -Who is Causing Them?

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SolutionsPerform denial study based on physician

responsibilityEducate and Provide support to physicians

and office staff to improve denial rates

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Line Item Denial Report Track denials by payer Create denial report by HCPCS and reason for

denial Reports top denials by expected opportunity

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Modifiers

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Modifier 91 It may be necessary to repeat the same lab test on

the same day to obtain subsequent (multiple) tests results. Under those circumstances modifier 91 may be appended. This modifier may only be used for lab tests performed more than once on the same day.*

* AMA CPT® Manual

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Hard-Coded 59 Modifiers Take the opportunity to verify the function of

hard-coded 59 modifiers. Replace with new X_ modifiers

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MUEs Two kinds of MUEs

Line Limit per line item

DOS All lines summed to DOS

Adjudication Indicator in MUE table “1” indicates that the edit is a claim line MUE “2” or “3” indicates that the edit is a DOS MUENCCI Policy Manual Chapter 1

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MUEs and Modifiers Modifiers may be used to bypass MUEs on separate

lines “Providers/suppliers should be cautious about

reporting services on multiple lines of a claim utilizing modifiers to bypass MUEs. MUEs were set so that such occurrences should be uncommon”

NCCI Policy Manual Chapter 10- Lab

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Questions and Discussion

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Contact UsRichard Cooley

Phone: 518-430-1144Email: RCooley@EpochHealth.Com

Jean RussellPhone: 518-369-4986Email: JRussell@EpochHealth.Com

Matt LawneyPhone: 845-642-6462Email: MLawney@EpochHealth.Com

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http://www.EpochHealth.com/

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CPT®

Current Procedural Terminology (CPT®) Copyright 2015 American Medical AssociationAll Rights ReservedRegistered trademark of the AMA

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DisclaimerInformation and opinions included in this presentation are provided based on our interpretation of current available regulatory resources. No representation is made as to the completeness or accuracy of the information. Please refer to your payer or specific regulatory guidelines as necessary.