Pathology/Lab Coding Alert

Laboratories have new Medicare direction that clarifies and simplifies a host of issues. Published as the "Final Rule for Coverage and Administrative Policies for Clinical Diagnostic Laboratory Services" in the Nov. 23, 2001, Federal Register, the directive establishes national policies and curtails the discretion of individual Medicare carriers while promoting uniformity for clinical lab tests.
 
The provisions of the rule, which clarify coding and claims submission requirements, should be fairly easy to implement and may improve reimbursement for laboratories, says Dennis Padget, CPA, FHFMA, president of Padget and Associates, a Kentucky-based pathology compliance consulting firm.
 
According to CMS administrator Tom Scully, "The Final Rule will make it easier for physicians to order lab tests they need to diagnose and treat their patients, and for labs to be reimbursed for the medically necessary services they provide." Most of the administrative requirements delineated in the rule are effective Feb. 21, 2002, while the new national coverage policies for 23 clinical laboratory tests will not go into effect until Nov. 25, 2002. The rule applies to all lab tests payable under Part B, regardless of setting (hospital, independent lab via physician office, or critical access hospital), ordered by a physician or qualified nonphysician practitioner.
 
The new, uniform coverage policies for tests such as urine cultures (e.g., 87086-87088) and blood counts (e.g., 85007-85048) will replace the current hodgepodge of local medical review policies (LMRPs) for the 23 laboratory tests outlined in the final rule. "Since, according to CMS, approximately 60 percent of laboratory claims will be subject to these regulations, the impact on laboratories could be enormous,"  Padget says.
 
The impact on a laboratory will depend on how much the new policies vary from the individual LMRPs now in place for that locality, according to Kenneth Wolfgang, MT (ASCP), CPC, CPC-H, member of the national advisory board of the American Academy of Professional Coders and director of coding and analysis for National Health Systems Inc., a coding consultation company in Camp Hill, Pa. "Having national coverage standards for these tests will be especially beneficial for labs that operate under the jurisdiction of more than one carrier and are subject to conflicting LMRPs."
Documentation Not Required by Physicians
"The most disappointing aspect of the final rule is that it does not mandate that the physician who orders the test furnish the requisite medical-necessity information," Padget says. "It leaves labs in the age-old bind, where the lab stands to suffer a Medicare claim denial if the ordering physician fails to supply adequate diagnostic information." The final rule codifies documentation and recordkeeping requirements to ensure that the ordering physician maintains documentation of medical necessity in the medical record, and that the laboratory maintains the documentation it receives from [...]