PHYSICIAN AND CLIENT RESPONSIBILITY

UP Health System – Marquette Reference Laboratory has a fiduciary responsibility to remind physicians that when they order tests in which Medicare/Medicaid reimbursement will be sought, physicians should only order tests that are "medically necessary." This means that only tests which are required for the diagnosis or treatment of a patient can be ordered and reimbursed by Medicare/Medicaid. This government policy eliminates most testing for screening purposes only. Exceptions and Requirements are noted on following pages.

Medicare Patients Must Pay For Tests Ordered Outside Utilization Guidelines

Utilization parameters have been developed based on comments received from Medicare's Carrier Advisory Committees and Professional Consultants for laboratory tests. The parameters represent the normal utilization of the test. Medicare recognizes that some clinical conditions may require testing at a frequency exceeding these guidelines. Likewise, providers may find testing at lower frequencies to be appropriate. Claims submitted for services that exceed these guidelines require additional documentation before payment is made.

For services provided through UPHSM outpatient collection centers, or samples submitted to our Reference Laboratory, it is the responsibility of the ordering physician and laboratory client to submit all medical necessity documentation, including all clinically relevant ICD-9 codes for each test on the laboratory requisition at the time of the test order. The ICD-9 codes submitted shall indicate the reason for laboratory testing and not for the patient visit.

Delays in service may be experienced by patients presenting to UPHSM outpatient collection centers with laboratory orders from their physician lacking medical necessity documentation for tests ordered, or the patient may be asked to sign an Advance Beneficiary Notice (ABN) accepting financial responsibility for those tests of which Medicare is likely to deny payment. Therefore, it is important that the laboratory requisition or physician order provides complete medical necessity documentation.

For specimens submitted to our Reference Laboratory, the requisition accompanying the specimen will include all medical necessity documentation.

Important Points to Remember:

  • ICD-9 diagnosis codes in conjunction with a narrative are the only acceptable form of medical necessity documentation.
  • ICD-9 code(s) submitted must be consistent with documentation in the patient's record.
  • When choosing an ICD-9 code, always select the code that most accurately describes the patient's condition and reason for testing. The codes should be of the highest level of specificity.
  • Only physician office or client staff authorized and experienced with coding should provide ICD-9 codes for laboratory services.
  • Providing ICD-9 codes on the Laboratory Requisition will avoid unnecessary phone calls to physician and client offices as well as delays in service to patients to obtain medical necessity documentation.
  • An ABN form must be submitted with each lab requisition when a limited coverage test is ordered without an ICD-9 code that supports the medical necessity of the test.

Procedures of Questionable Current Usefulness

The following tests are considered "Procedures of Questionable Current Usefulness" by Medicare and require documentation which satisfactorily establishes the procedure's medical necessity (letter of medical necessity). The reference is Medicare Medical Policy Bulletin No. G-33. If a letter of medical necessity can not be provided, please have the patient sign the Patient Waiver section of the requisition form, so the patient will be billed directly for the test.

  • 17-HYDROXYPREGNENOLONE 84143
  • 3-ALPHA ANDROSTANEDICOL-G 82154
  • ARSENIC 24 HR. URINE 82175
  • ARSENIC BLOOD 82175
  • ATRIAL NATRIURETIC FACTOR (ANF) 83880
  • BETA ENDORPHIN 84999
  • CORTICOTROPIN RELEASING HORMONE 84999
  • ENDOTHELIN-I 84999
  • FELBAMATE 80299
  • FIBRONECTIN AGGREGATES, IGG 84999
  • FOSCARNET, SUSCEPTIBILITY 87999
  • HEXOSAMINIDASE A (TAY SACHS) 84999
  • HYDROXYCORTISOL 18 84999
  • INSULIN-LIKE GROWTH FACTOR II 84999
  • INTERLEUKIN-1b (IL-1b) 84999
  • INTERLEUKIN-6 (IL-6) 84999
  • KETOSTEROIDS 17-, (17-KS) TOTAL 83586
  • LEAD, URINE (24 HR.) 83655
  • LEUCINE AMINOPEITIDASE, SERUM 83670
  • MELANO. STIM. HORMONE (GAMMA) 84999
  • MELANO. STIM. HORMONE (BETA) 84999
  • MELANO. STIM. HORMONE (ALPHA) 84999
  • METHYLDOPA (ALDOMET) 80299
  • MHPG, 24HR. URINE 84999
  • MYELOPEROXIDASE Ab. 84999
  • NATURAL KILLER CELL FUNCTION 86849
  • NEURONTIN (GABAPENTIN), SERUM 80299
  • NITROGLYCERINE 80299
  • NORRISE DISEASE TESTING 86849
  • PEPSINOGEN, SERUM 80101
  • PROPOXYPHENE, URINE, QUAL. 80099
  • SELENIUM, SERUM 84255
  • SILVER LEVEL, 24 hr. 82190
  • SULFATIDE ANTIBODY, IGM 84999
  • THIOTHIXENE, PLASMA 80299
  • THYROTROPIN RELEASING HORMONE 84999
  • TOCAINIDE LEVEL 80299
  • TRYPSINOGEN, SERUM 84999
  • TRYPTASE, SERUM 84999
  • The practitioner should discuss the possibility of claim denial with the patient and the reason(s) the test should be performed so s/he is able to make an informed decision whether or not to proceed with the service.

    The ABN consists of four required components: Patient Demographic information (Name, Medical Record Number, Date of Service, Medicare HINC#), The test(s) subject to the ABN, the patient's desire to have the test performed (YES, it should be performed and the patient will pay for it or NO do not perform the test), The patient's signature and date.