Laboratory Billing Industry Updates, October 2023
This Month’s Message from Jim O'Neill: ?
Coding Changes = AMA Conflict with Big MACs
I couldn’t resist the Big MAC reference. Still, it?is?true: some Medicare Administrative Contractors (MACs) are changing the CPT codes that clinical laboratories submit for infectious disease testing so that the labs are reimbursed for only one code instead of multiple codes.
Specifically and supposedly, certain MACs are changing codes for sexually transmitted infection testing and paying less. Essentially, it appears some payers are literally “gaming the CPT coding system” to enable lower reimbursements to benefit themselves (the MACs).
At its core is a conflict between the National Correct Coding Initiative (NCCI) Policy Manual coding guidance - which happens to be a general reference tool used by MACs - and the AMA’s CPT codebook, which says laboratory procedures should be coded at the highest level of specificity.
Directly from the 2021 NCCI Policy Manual: “If a laboratory procedure produces multiple reportable results, only a single HCPCS/CPT code shall be reported for the procedure. If there is no HCPCS/CPT code that describes the procedure, the laboratory shall report a miscellaneous or unlisted procedure code with a single unit of service.”
Some MACs have begun following the CCI guidance rather than the AMA CPT instructions.
For example, Anthem Blue Cross Blue Shield announced late in 2021, about a policy for STI testing effective Dec. 1, 2021 in several states including but not limited to, CO, CT, GA, IN, KY, ME, MO, NV, NH, NY, OH, and WI.
The same approach appears to have been adopted by AmeriGroup Medicare Advantage and BCBS of Minnesota, among others. Anthem is on record that CPT codes 87491, 87591, and 87661 are part of a laboratory panel grouping unless provider, state, or federal contracts or requirements indicate otherwise.
What about modifiers? They won’t override this new policy, according to Anthem.
Again, for example, with STIs, if a provider orders tests for three different infectious agents (generally Chlamydia trachomatis, Neisseria gonorrhoeae, and Trichomonas vaginalis), the lab will bill only 87801 instead of the three more specific codes and will receive a single payment of $70.20 rather than three separate payments of $35.09 ($105.27).
It’s all very daunting and deeper than the relative thumbnail presented above. And that’s precisely why we’re here! Our laboratory billing team will ensure all of your claims are submitted correctly and for maximized reimbursements without you having to dwell on this minutiae.
Give me a call to talk more about how we can help you. Even better, if you’re attending next month’s AMP conference in Salt Lake City, see us at booth 702!
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Laboratory AI Updates
Regardless of anyone’s particular opinion about AI, it’s undeniably here:?
·???????? AI helps ID patients with advanced lung cancer who respond to immunotherapy, as shown by Yale Cancer Center researchers at the Yale School of Medicine.
AI-powered digital scoring was compared with traditional manual scoring of the PD-L1 immune biomarker to determine if atezolizumab, a new immunotherapy treatment, could help patients with advanced non-small cell lung cancer. PD-L1 expression is considered the best biomarker to predict responsiveness to immune-checkpoint inhibitors.
The AI model identified more patients as PD-L1 positive than the conventional manual scoring. ?
Click here for all of the details from the Yale School of Medicine.
·???????? AI-based tool predicts the primary source of a patient’s cancer using tumor gene sequencing data. Developed by researchers at Dana-Farber Cancer Institute, OncoNPC could help guide cancer treatment and improve outcomes in difficult-to-diagnose cases.
The researchers trained and validated a machine learning classifier using the medical records of 36,445 patients with known primary tumors from Dana-Farber and two other major cancer centers. ?
OncoNPC accurately predicted the origin of about 80% of tumors with known types, including metastatic tumors, using a subset of cases that had not been used as training data. The model made high-confidence predictions in 65% of the tumors, meaning it assessed its prediction as having a high probability of being correct. Those predictions were 95% accurate.
Click here to read about details and stats in Dana-Farber’s press release.
·???????? AI can effectively detect and diagnose Polycystic Ovary Syndrome (PCOS), according to a new study by the National Institutes of Health (NIH). Researchers found that AI-based programs were able to detect PCOS successfully.
Study authors suggested integrating large population-based studies with electronic health datasets and analyzing common laboratory tests to identify sensitive diagnostic biomarkers that can facilitate the diagnosis of PCOS.
We selected only three random clips from dozens of recent AI articles of interest to laboratories.
Speaking of AI, MedicsPremier, the platform we use for laboratory claims submission and patient billing, EDI, out-of-network alerts, eligibility verifications, financial and operational analytics, and more, is AI-driven as well. Combined with our outsourced workforce, your staffing issues and tedious “hands-on the system” time can be dramatically consolidated.
The same MedicsPremier system is available from ADS if in-laboratory automation is preferred.
Contact us for more about MedicsRCM, MedicsPremier, or both!
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LDTs, FDA, and (Possibly) You
The FDA has proposed a rule, the essence of which is to help ensure the safety and effectiveness of LDTs (laboratory-developed tests). Safety concerns over LTDs have been an ongoing issue.
The rule would require vitro diagnostic products (IVDs) to be under the Federal Food, Drug, and Cosmetic Act, including when the IVD manufacturer is a laboratory.
Additionally, the FDA is suggesting that it (the FDA) provide greater oversight of LDTs, gradually phasing out its now less restrictive general enforcement discretion approach to LDTs. Ostensibly, this would better protect public health by helping to assure the safety and effectiveness of IVDs offered as LDTs while avoiding disruptions to the testing market.
After this phase-out, the FDA generally expects IVD makers to meet the same applicable requirements, except where specific requirements under the Clinical Laboratory Improvement Amendments can be leveraged.
Click here for all the details and ramifications of the FDA’s proposed LTD rules.?
领英推荐
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$262M for National Network for Outbreak Response and Disease Modeling
The CDC has announced that $262 million will be awarded to 13 entities to establish an Outbreak Analysis Disease Modeling Network, which will design and support state and local decision-makers in developing and implementing new tools to detect, respond to, and mitigate public health emergencies more effectively.
It will include building and scaling needed capabilities best suited for each of the 13’s respective jurisdictions, comprising public, private, and academic sectors.
?Click here for the details and to see the 13 entities.
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If you Submit Claims to Oscar
And the Oscar goes to…oops, wrong Oscar.
If you’re in one of the approximately 30 states where claims can be submitted to Oscar, you might already know about certain issues with those claims.
In a nutshell, and according to Oscar, some claims have been on hold for quite some time while Oscar has tried to offset the full amounts. With a new process implemented, Oscar will be able to appropriately offset these payments.
A temporary increase in the amount of offsetting applied to payments from this backlog may be seen, but that’ll only be the case until Oscar can reconcile these amounts.?
Submitters will be able to find all the information about any overpayments, refund requests, and offsetting on their EOP/835. ?
Some special cases where comments on your EOP/835 may look different than the above. Oscar has created a guide for you to review for more information on when you may see these and what they mean.
Visit Oscar (hioscar.com) for more details.
(MedicsRCM has Oscar claims covered, and our success rate is nearly 100% on first-attempt clearinghouse submissions.)
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October Laboratory Fraud Story
In a press release dated 10/3/23, the US Attorney’s Southern District (FL) Office announced that the former owner of a laboratory was ordered to forfeit over $187 million in fraudulently-obtained proceeds, including over $30 million from personal and corporate bank accounts, a 2018 Ferrari, a 2019 Land Rover, and real estate.
The fraud involved expensive genetic tests performed on Medicare patients with patient brokers signing “sham” contracts about performing legitimate testing. Kickbacks and bribes also involved telemedicine companies whereby doctors would sign-off on prescriptions for the tests even though they weren’t treating the beneficiaries.
As for prison time, he was sentenced to 27 years on 8/18/23.
Click here for the details on the fine, and here for the sentencing.
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Managing Laboratory Sales Teams
Suppose you have a sales team or even a single salesperson. In that case, you have another level of unwanted minutiae to deal with in tracking and reporting on productivity and providing the data they need. It’s just another nuisance you have to live with.
But wait! What if you could provide your salesperson or team with a self-serve app enabling them to see their data at any time, on-demand, without having to disrupt your finance, administrative, or HR staff?
MedicsRCM has a built-in (no extra cost)?sales portal/app?your team can use to cull and view their productivity data anytime without bothering anyone else on your staff. The same capability is available in MedicsPremier if an in-laboratory billing/workflow platform is preferred.
BTW…speaking of your staff, the MedicsRCM outsourced workforce (also built-in at no additional cost) can help consolidate your in-laboratory staffing issues by taking up an array of “busywork” routines on billing, claims, prior authorizations, out-of-network alerts, EDI, verifications, denial prevention and management, patient statements and patient questions, EOB reconciliations, insurance discovery, and more.
You can empower your sales team to be more self-sufficient and less dependent on your other resources while you operate more efficiently in general.
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Contact us at 844-599-6881 or email [email protected] for more about our outsourced MedicsRCM services for your laboratory and our guarantee to increase your revenue in 90 days, or about the MedicsPremier platform implemented on your server or our cloud if an in-laboratory system is preferred.
Or see us at AMP in Salt Lake City, booth 702!
Next up: ?November’s post-AMP edition with items and articles of interest to laboratorians.?
Feedback or comments on our newsletters/content are greatly appreciated. Please opine by emailing [email protected] or by calling me at 973-931-7516. I would love to hear from you!
Marc E. Klar, Vice President, Marketing, ADS RCM.
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Disclaimer:? Articles and content about governmental information, such as CMS, Medicare, and Medicaid, are presented according to our best understanding. Please visit www.cms.gov if clarifications are needed. We are not responsible for typographical errors or changes that may have occurred after this newsletter was produced. Visit www.adsc.com to view our most up-to-date information. ADS RCM does not endorse any companies mentioned in our newsletters; you are encouraged to do research and due diligence on any that might interest you. ?