Organ and Disease Panels - HCA Healthcare
| SCOPE: All Company-affiliated hospitals performing and/or billing laboratory services. Specifically, the following departments: |
| |
|Business Office Nursing |
|Admitting/Registration Laboratory |
|Administration Case Management |
|Revenue Integrity Shared Services Centers |
|Health Information Management |
|Reimbursement |
|PURPOSE: To establish guidelines for billing Organ and Disease panels in accordance with Medicare, Medicaid, and other federally-funded payer |
|requirements. |
|POLICY: Organ and Disease panels and component tests billed to a federally-funded program must be based on a written order and be medically |
|necessary. Only the Centers for Medicare and Medicaid Services (CMS)-approved Organ and Disease panels will be billed at the panel level to |
|Medicare, Medicaid and other federally-funded payers, unless the payer has provided written documentation regarding the acceptance of other American|
|Medical Association defined Organ and Disease panels. Chemistry components will be bundled to the panel level when all of the tests in the panel |
|are ordered and performed. |
| |
|Repeated laboratory tests, including repeated 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. |
| |
|If a CPT code is a component of a CMS-approved Organ and Disease panel, a subsequent test performed on a different specimen type may be billed when |
|medically necessary, which is indicated by reporting modifier 59. If a payer does not recognize or accept modifier 59 and the payer has not |
|provided you with their specific billing guidance for repeated laboratory tests, these tests may not be billed. |
| |
|CMS has established Medically Unlikely Edits (MUE) and National Correct Coding Initiative (NCCI) edits. MUEs may trigger when units of service on a |
|given claim line item exceed the established limit for that HCPCS code. NCCI edits may trigger when there are restrictions on code combinations |
|reported on a single date of service. MUEs and/or NCCI edits may supersede information within this policy. |
|PROCEDURE: The following steps must be performed when billing Organ and Disease panels to Medicare, Medicaid, and other federally-funded programs. |
| |
|IMPLEMENTATION |
|Assign CPT/HCPCS codes and revenue codes for each panel and panel component test in accordance with the Company Standard Laboratory Chargemaster. |
|Set-up the Laboratory and Order Entry dictionaries or masterfiles to enable the ordering and billing of panels. |
| |
|80047 Basic Metabolic Panel (Calcium, Ionized) National Limit Amount $11.91 |
|Revenue Code 301 |
|Calcium, ionized (82330) |
|Carbon dioxide (82374) |
|Chloride (82435) |
|Creatinine (82565) |
|Glucose (82947) |
|Potassium (84132) |
|Sodium (84295) |
|Urea Nitrogen (BUN) (84520) |
| |
|80048 Basic Metabolic Panel (Calcium, Total) National Limit Amount $11.91 |
|Revenue Code 301 |
|Calcium, total (82310) |
|Carbon dioxide (82374) |
|Chloride (82435) |
|Creatinine (82565) |
|Glucose (82947) |
|Potassium (84132) |
|Sodium (84295) |
|Urea nitrogen (BUN) (84520) |
| |
|80051 Electrolyte Panel National Limit Amount $ 9.87 |
|Revenue Code 301 |
|Carbon dioxide (82374) |
|Chloride (82435) |
|Potassium (84132) |
|Sodium (84295) |
| |
|80053 Comprehensive Metabolic Panel National Limit Amount $14.87 |
|Revenue Code 301 |
|Albumin (82040) |
|Bilirubin, total (82247) |
|Calcium, total (82310) |
|Carbon dioxide (82374) |
|Chloride (82435) |
|Creatinine (82565) |
|Glucose (82947) |
|Phosphatase, alkaline (84075) |
|Potassium (84132) |
|Protein, total (84155) |
|Sodium (84295) |
|Transferase, alanine amino (ALT),(SGPT) (84460) |
|Transferase, aspartate amino (AST) (SGOT) (84450) |
|Urea nitrogen (BUN) (84520) |
| |
|80061 Lipid Panel National Limit Amount - None |
|Revenue Code 301 State Range: Low: $11.83 High: $14.87 |
|Cholesterol, serum, total (82465) |
|Lipoprotein, direct measurement, |
|high density cholesterol |
|(HDL cholesterol) (83718) |
|Triglycerides (84478) |
| |
|80069 Renal Function Panel National Limit Amount $12.22 |
|Revenue Code 301 |
|Albumin (82040) |
|Calcium; total (82310) |
|Carbon dioxide (82374) |
|Chloride (82435) |
|Creatinine (82565) |
|Glucose (82947) |
|Phosphorus inorganic (phosphate) (84100) |
|Potassium (84132) |
|Sodium (84295) |
|Urea nitrogen (BUN) (84520) |
| |
|80074 Acute Hepatitis Panel National Limit Amount – None |
|Revenue Code 300 State Range: Low: $57.92 High: $67.01 |
|Hepatitis A antibody (HAAb), IgM antibody (86709) |
|Hepatitis B core antibody (HBcAb), IgM antibody (86705) |
|Hepatitis B surface antigen (HBsAg) (87340) |
|Hepatitis C antibody (86803) |
| |
|80076 Hepatic Function Panel National Limit Amount $11.49 |
|Revenue Code 301 |
|Albumin (82040) |
|Bilirubin; total (82247) |
|Bilirubin; direct (82248) |
|Phosphatase, alkaline (84075) |
|Protein, total (84155) |
|Transferase, aspartate amino (AST) (SGOT) (84450) |
|Transferase, alanine amino (ALT) (SGPT) (84460) |
| |
|Business Office or Service Center personnel must verify that edits are present in the electronic billing system which: |
|Bundle individual component tests to the most comprehensive panel level as defined in this procedure. |
|Compare individual component tests within each panel to any component tests not billed as part of a panel and identify repeated tests. |
|Compare individual component tests of multiple panels and identify duplicate components. |
| |
|Laboratory and Business Office/Service Center personnel must educate all staff associates responsible for ordering, charging, or billing laboratory |
|services regarding the requirements of this policy. |
| |
|Monitoring activities must be completed in accordance with the Billing – Monitoring Policy, REGS.GEN.001. |
| |
|DAILY |
|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: |
|Bundle individual component tests to the most comprehensive panel level as defined in this procedure. |
|Compare individual component tests within each panel to any component tests not billed as part of a panel and identify repeated tests. |
|Compare individual component tests of multiple panels and edit for duplicate components. |
| |
|Service Center or Business Office personnel must review electronic billing edit/error reports daily and perform the following: |
|Bundle chemistry components to the appropriate comprehensive panel. |
|Identify the presence of repeated panels and component tests and determine if documentation is present to support medical necessity. |
|Append the appropriate modifier (59 or 91) to repeated tests or panels which are medically necessary. |
|Eliminate repeated tests or panels which are not medically necessary. Modify number of units and related charges in the electronic billing vendor |
|system to reflect the appropriate charge for the panel being billed. |
| |
| |
|The Facility Ethics and Compliance Committee is responsible for implementation of this policy within the facility. |
|REFERENCES: |
| |
|Medicare Claims Processing Manual, Chapter 16, Section 90 |
|AMA CPT Assistant, Summer 1993 Pages: 14-15 |
|AMA CPT Assistant, January 1998 Pages: 7-8 |
|American Medical Association Physicians’ Current Procedural Terminology CPT |
|Current Year Clinical Lab Fee Schedule |
|CMS website - National Correct Coding Initiative edits |
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