May 11, Dear Physician: billing practices and compliance policies. communication.

Transcription

1 Laboratory Services 600 Gresham Drive Norfolk, VA compliance May 11, 2017 Dear Physician: Sentara Reference Laboratory is proud to serve the physicians and patients of Southeastern Virginia and Northeastern North Carolina. As Hampton Roads only full-service reference laboratory, each year Sentara Reference Laboratory (SRL) discloses information about our billing practices and compliance policies. inside: This letter is to provide healthcare professionals with a written communication addressing various policies that affect ordering, performing and billing clinical laboratory tests. Details regarding Sentara Reference Laboratory s policies are contained in this communication. If you have any questions or would like more information about the topics covered in this compliance communication, I may be contacted at 757/ or via at KPBEHM@sentara.com. If you have questions about any other services that Sentara Laboratory Services offers, please contact your Marketing Representative, visit our website at or contact Client Services at 757/ Sincerely, Kim Behm Compliance Offi cer Sentara Laboratory Services Test Ordering, Performing and Billing Policies Clinical Consultant List Medicare Lists 1

2 Clinical Consultants Clinical consultant services are available by contacting the following professionals: clinical consultants Clinical Services: Stephanie Spingarn, M.D., Director, 757/ Valerio M. Genta, M.D., (SVBGH), 757/ Cytogenetics: Jennifer Winters, Ph.D., Director, 757/ Molecular Diagnostics: Suhail Nasim, M.D., Director, 757/ Flow Cytometry: Stephen Fisher, M.D., 757/ W. Tang, M.D., (SVBGH), 757/ Cytology: Robert Pu, M.D., 757/ June Shen, M.D., (SVBGH) 757/ Surgical Pathology All surgical pathology testing will incur separate professional charges. Other clinical tests and pap smears, based on results, may also incur separate professional charges. Professional charges appear on a separate bill from testing. A list of clinical tests that have a separate professional charge is included below. Clinical Test Code B-Cell Rearrangement IGH; B-Cell Rearrangement IGK; T-Cell Rearrangement Beta; T-Cell Rearrangement Gamma; Blood Platelet Aggregation; BRAF; Crystal Examination; Cystic Fibrosis DNA 97; Cystic Fibrosis DNA 145; EGRF; Fibrinolysins/Coagulopathy; Clinical Test Code Fragile X Analysis Hemoglobin Electrophoresis; 83020, Jak-2 Mutation; KRAS; 81275, Protein Electrophoresis - serum; Protein Electrophoresis - urine; CSF; Smear, Parasites (malaria, etc.); Protein Immunofi xation (IFE) Serum; Urine, CSF; Pathologist Review of Smear clinical pathology 2

3 Advance Beneficiary Notices (ABN) An Advanced Beneficiary Notice (ABN) should be completed if any of the laboratory services ordered for a Medicare patient are not accompanied by a diagnosis code eligible for coverage by Medicare. Medicare will only pay for services that it determines to be reasonable and necessary. Before the laboratory service is performed, the benefi ciary should be notifi ed in writing with an ABN. After reviewing the ABN, the benefi ciary has the choice to sign the ABN agreeing to receive the service and to pay for it, or not to receive the service. The ABN must clearly identify the specifi c test, the estimated cost, and give the reason(s) that payment is likely to be denied and be dated. Requesting an ABN from all Medicare benefi ciaries or requesting benefi ciaries sign a blank ABN are considered unacceptable practices. Medical Necessity Laboratory Services Patient Name: Identification Number: Advance Beneficiary Notice of Noncoverage (ABN) 600 Gresham Drive Norfolk, VA Phone: 757/ Fax: 757/ NOTE: If Medicare doesn t pay for laboratory test(s) listed below, you may have to pay. Medicare does not pay for everything, even some care that you or your health care provider have good reason to think you need. We expect Medicare may not pay for the laboratory test(s) listed below Laboratory Test(s) Alpha-fetoprotein BNP Beta HCG (1 per month for diag.) CA 125 CA 15-3/CA CA 19-9 CEA (1 per chemo cycle or bi-monthly for post surgical colectoral carcinoma) CRP HS Collagen Crosslinks (4 in first year, annual thereafter) Cholesterol Digoxin Ferritin GGT Glucose Hepatic Function Panel Hepatitis Panel Acute HGB A1c (every 3 mos. for controlled diabetic, 1 per mo. if pregnant) HIV Diagnostic HIV Prog/Monitoring Homocysteine Iron Studies Lipids Magnesium Occult Blood PAP PSA (1 per year) PTH Intact PT-INR PTT Sed Rate Thyroid testing (2 per year) Transferrin Triglycerides Urine Culture & Sens. Vitamin D WHAT YOU NEED TO DO NOW: Read this notice, so you can make an informed decision about your care. Ask us any questions that you may have after you finish reading. Choose an option below about whether to receive the laboratory test(s) listed above. Note: If you choose Option 1 or 2, we may help you to use any other insurance that you might have, but Medicare cannot require us to do this. OPTIONS: Check only one box. We cannot choose a box for you. OPTION 1. I want the laboratory test(s) listed above. You may ask to be paid now, but I want Medicare billed for an official decision on payment, which is sent to me on a Medicare Summary Notice (MSN). I understand that if Medicare doesn t pay, I am responsible for payment, but I can appeal to Medicare by following the directions on the MSN. If Medicare does pay, you will refund any payments I made to you, less co-pays and deductibles. OPTION 2. I want the laboratory test(s) listed above, but do not bill Medicare. You may ask to be paid now as I am responsible for payment. I cannot appeal if Medicare is not billed. OPTION 3. I don t want the laboratory test(s) listed above. I understand with this choice I am not responsible for payment and I cannot appeal to see if Medicare would pay. Additional Information: This notice gives our opinion, not an official Medicare decision. If you have other questions on this notice or Medicare billing, call MEDICARE ( /TTY: ). Signing below means that you have received and understand this notice. You also receive a copy. White - Send to Sentara Yellow - Physician copy Pink - Patient copy Claims submitted for laboratory services will only be paid by Medicare if the service is covered, reasonable, and necessary for the benefi ciary given his or her clinical condition. Medicare may deny payment for test(s) a physician believes is appropriate, but that does not meet the Medicare coverage criteria, such as for screening. ICD-10-CM diagnosis codes must be provided for each laboratory service ordered. If you have questions about Medicare Approved Diagnosis contact your Marketing Representative or Client Services at 757/ Signature: Date: Reason Medicare May Not Pay: Medicare does not pay for this test for your condition. Medicare does not pay for this test as often as this (denied as too frequent). Medicare does not pay for experimental or research use tests. Estimated Cost According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is The time required to complete this information collection is estimated to average 7 minutes per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of the time estimate or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Baltimore, Maryland Form CMS-R-131 (03/11) Form Approved OMB No policies & procedures Laboratory Requisitions SRL requires the use of one of our standard test requisitions that can be submitted by courier or electronically via the internet. Using our requisition allows for accurate and effi cient patient registration, processing and billing. Attaching a copy of the patient s insurance card ensures that correct insurance information is received by the laboratory. Specimen labels containing the requisition number and bar code are provided. Placing a requisition identifi cation label on each patient specimen in addition to the patient name will help prevent misidentifi cation, processing errors or delays. Supply Requests SRL provides specimen collection supplies for SRL testing only. Please be sure to order Sentara supplies each month based on the amount of SRL testing you expect to process. Orders may be adjusted if supplies ordered do not correspond with the testing SRL has received. 3

4 reimbursement listing Test and Medicare Listing Refl ex testing, test panels and profi les with multiple billable codes are listed in the charts on the following pages with corresponding codes and expected Medicare reimbursement Reflex Phys 2017 Reflex Ordered Test Medicare Reflex Test Fee Medicare Reimb Sch Reimb ANA Screen ANA Titer Anti-neutrophil Cytoplasmic AB APC-R with reflex Body Fluid Cell Count Clostridium Difficile Assay Cryptococcal Antigen (serum or fluid) If P-ANCA + = MPO antibody If C-ANCA + = PR-3 antibody If less than 2, Factor V Leiden If abnormal cells noted Body Fluid Pathologist Review Clostridium Difficile Molecular Cryptococcal Antigen Titer (serum or fluid) Y Culture, AFB M. tuberculosis by PCR Culture, Anaerobic Culture, Blood Culture, Urine Culture, Other includes respiratory, wound and or abscess Culture, Stool Sensitivity (may be more Sensitivity (may be more Sensitivity (may be more Sensitivity (may be more Sensitivity (may be more Culture, Fungus Culture, Throat Strep Only Fungus identification (may be more * Includes professional fees

5 Ordered Test 2017 Medicare Reimb Reflex Test Reflex Reflex Phys Fee Sch 2017 Medicare Reimb Direct Antiglobulin Monospecific Testing For each positive test, Drug Screen the Quantitative test is ordered Ectopic Preg Beta HCG Serum Panel (quant) Hep C Hep C Virus Quant Hep C Genotype HCV RNA PCR HIV Ab by EIA HIV HIV If is test is non-reactive HIV-1 RNA Qual HIV-1 Genotype HIV RNA PCR Homocystein MTHFR Lipid Complete LDL-C if triglyceride > Lupus Anticoagulant Screen Lyme Abs Pap Smear, Liquid Based Rapid Strep Screen If positive Lupus Anticoagulant Confirmatory test Lyme Western Blot IgG & IgM If ASCUS, then HPV amplified range If neg, then culture, throat strep only Sickle Cell Screen Path Smear Interpt Y HGB Electrophoresis with inter Syphilis IgG Ab RPR Titer TP-PA Thyroid Cascade TSH T4 Free T3 Free Thyroid Replacement TSH T4 Free Urinalysis automated 81003, microscopic if indicated If microscopic indicated then credited and Urinalysis automated with microscopy is billed * Includes professional fees 5

6 2017 Medicare Frequently Ordered Tests with Multiple Billable Protein A/G Ratio AFP TETRA Screen (Maternal) Allergy Clinic Profile Ige Allergy Drug Allergy Panel IgE Allergy Dust Allergen Panel IgE Allergy Eastern Agriculture Regional Mixed Panel IgE Allergy Food Pediatric Panel IgE Allergy Food Profile IgE Allergy Grain Profile IgE Allergy Insect Venom IgE Profile Allergy Latex Related Prof IgE Allergy Legume Allergen Panel IgE Allergy Meat Allergen Panel IgE Allergy Mold IgE Panel Allergy Nut Profile IgE Allergy Pediatric Profile IgE Allergy Pollen Allergen Panel IgE Allergy Regional Profile IgE Allergy Tree Allergen Panel IgE ANA Comprehensive Panel Anaplasma Phagocytophilum Ab Antiphospholipid Syndrome Panel Antiplatelet Antibody (APA) Apolipoprotein Panel APTT 1:1 Normal Mix

7 Frequently Ordered Tests with Multiple Billable 2017 Medicare APTT 1:1 Normal Mix (cont.) Arboviral IgG Antibodies Babesia Ab Bacterial Vaginosis Bacterial Vaginosis and Candida Bacterial Vaginosis, Candida, Trich Vaginalis, and HSV 1&2 NAA Bacterial Vaginosis, Candida, Trich Vaginalis, and HSV 1&2 NAA + Chlamydia Bartonella Antibodies (Cat Scratch) Beta-2 Glycoprotein Antibodies Bilirubin, Indirect Bordetella Pertussis/ Parapertussis/Holmesii PCR Bordetella Pertussis IgG/IgM Brucella Antibodies Candida 4 Species Profile, NAA Candida 6 Species Profile, NAA Candida albicans and Candida glabrata Cardiolipin Antibody Profile CD4/CD Celiac Panel Chlamydia Diff Antibody Panel Chlamydia/GC Nucleic Amp Chromium Urine Random Chromosome Study, Amniotic fluid

8 Frequently Ordered Tests with Multiple Billable 2017 Medicare Chromosone Study, Amniotic fluid (cont.) Chromosome Study, Blood Chromosome Study, Bone Marrow Chromosome Study, Chorionic Vil Chromosome Study, High Resolution Chromosome Study, Leukemic Blood/Lymph Node Chromosome Study, Solid Tissue Chromosome Study, Tumor CMV Avidity Test Cortisol Bind Glob w/free Cort Coxsackie A Virus AB Panel, CF Coxsackie B Virus AB Panel, CF Creatine Kinase Isoenzymes + Total CSF Profile Culture, Tissue

9 Frequently Ordered Tests with Multiple Billable 2017 Medicare Culture, Tissue (cont.) Dengue Fever Ab DIC Screen Echo Virus ABS, Panel Ehrlichia Antibodies ENA Antibodies Febrile Agglutinin AB Panel FISH Cytogenetic (per probe) FISH EGFR (non automated) Folic Acid, Serum/Vitamin B Free K&L Light Chains, QN, SER Fungal Antibody Screen, ID G-6-PD, Quant GC/Chlamydia Nucleic Amp GC/Chlamydia, Genital Mycoplasma Profile NAA-Swab GC/Chlamydia, Genital Mycoplasma Profile NAA-Urine GC/Chlamydia, HSV 1 and 2 NAA GC/Chlamydia, M. Genitalium NAA-Swab GC/Chlamydia, M. Genitalium NAA-Urine

10 Frequently Ordered Tests with Multiple Billable 2017 Medicare GC/Chlamydia, M. Genitalium NAA-Urine (cont.) GC/Chlamydia, Trich Vaginalis, HSV 1 and 2 NAA Genital Mycoplasma Profile NAA-Swab Genital Mycoplasma Profile NAA-Urine Globulin Glucose Tolerance Testing Heavy Metal Profile Heavy Metals Profile II, Blood Hematocrit and Hemoglobin Herpes 6 IgG and IgM ABS Herpes 7 IgG/IgM Herpes Simplex 1+2 IGG Herpes Simplex 1+2 IGM, IFA HIT Panel HIV-1 Phenotype HPV Low/High DNA Testing HPV PCR HSV 1 & 2 NAA Hyper Pneu Thermo Hyper Pneumo Aspergillus IGG Hyper Standard Battery IGG

11 Frequently Ordered Tests with Multiple Billable 2017 Medicare IgG Subclass Immune Complex Immunoglobulins IgG, IgA, IgM Influenza A H1N1 RT-PCR Influenza Antibodies, CF Influenza Rapid Screen Iron Profile I-STAT 6+ - Na, K, Cl, BUN, Glu, Hct I-STAT E3+ - Na, K, Hct I-STAT EC 4+ - Na, K, Glu, Hct I-STAT EG 6+ - Na, K, ph, PCO2, PO2,Hct Kidney Stone Urine Panel Lead Screen

12 Frequently Ordered Tests with Multiple Billable 2017 Medicare Lead Screen (cont.) Legionella Pneumophila IGM Legionella Pneumophila Total AB Leishmaniasis AB Lipid Panel, Initial Cholesterol HDL Lupus Anticoagulant Panel Lyme AB Western Blot Meningitis/Encephalitis Panel Metanepharine, Random Urine MMR Panel MMR with Varice Abs Motor and Sensory Neuropathy MS-Profile Muscle Antibodies Myasthenia Gravis Profile Nash FibroSure

13 Frequently Ordered Tests with Multiple Billable Note: Any culture with a gram stain will incur a separate charge. All abscess, CSF, expectorated sputum, body fl uid, bronchial, tissue and wound cultures will have a gram stain performed to provide rapid clinical information. Gram Stain, 87205, $5.81 Medicare. Medicare is based on clinical laboratory fee schedule published by Medicare. All AFB smears will have an AFB Culture performed, if suffi cient specimen is available. AFB Culture, 87116, $ Medicare. Medicare is based on clinical laboratory fee schedule published by Medicare Medicare Nash FibroSure (cont.) Neutrophil Cytoplasmic Abs Ova and Parasites Parainfluenza ABS, CF Parvovirus Panel PFA 100 Assay Phenosense GT Phosphatidic Acid, IgG, IgA, IgM Phosphatidylcholine, IgG, IgM, IgA Phosphatidylethanolamine ABS Phosphatidylinositol, IgG, IgM, IgA Phosphatidylserine, IgG, IgM, IgA Platelet Aggregation Polio ABS, CF Polio Neutralization Saccharomyces Cerevisiae AB Salmonella Antibodies (Widal) Serotonin Releasing Assay Serum Integrated Panel Sjogren s Antibodies Synovial Profile T and B Cell Panel Supergroup T and B Panel Pediatric * Includes professional fees 13

14 Sentara Laboratory Services 600 Gresham Drive Norfolk, VA Laboratory Compliance Letter Enclosed 14