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Physician Letter (April 2008) April 14, 2008 Dear Physician or Clinician: As part of the Wisconsin State Laboratory of Hygiene (WSLH) Medicare Compliance Plan, the WSLH annually reviews aspects of ordering tests for Medicare patients and billing for those tests. Please review this information and contact me (608-265-3537) if you have any questions relating to the information. CPT Codes The CPT codes that are submitted to Centers for Medicare and Medicaid Services (CMS) must be valid at the time the service is provided. 2008 CPT codes take effect on January 1, 2008. All discontinued codes will be invalid after that date. We will be using the 2008 CPT codes starting on January 1, 2008. Advance Beneficiary Notice (ABN) The WSLH requires that test submitters properly obtain and send to the WSLH a signed ABN (also known as a Waiver of Liability) when the physician/submitter believes there is a likelihood that Medicare will not pay for the test(s) being ordered from the WSLH. The ABN allows the beneficiary to make an informed decision about the services before the service is performed. If payment is denied by Medicare, we will seek reimbursement from the submitter/physician. A copy of the current ABN form and Advanced Beneficiary Notice Form Instructions are available at this Web site, /compliance/medicare/index.dot. Medical Necessity Medicare wants to be sure that physicians realize that when requesting tests for which Medicare reimbursement will be sought, they should only order tests that are medically necessary for the diagnosis or treatment of the affected patient. Medicare may deny payment for a test even though the physician believed it was "appropriate" if the test did not meet Medicare's definition of medical necessity. According to Section 1862(a)(1)(A) of the Social Security Act, Medicare does not pay for services that: "Are not reasonable and necessary for the diagnosis or treatment of illness or injury or to improve the functioning of a malformed body member". This has generally been interpreted to mean Medicare does not pay for routine physical checkups or screening services. Some tests, such as a screening Pap Smear, are limited by frequency and thus covered by Medicare only once every 24 months in most circumstances. Local Coverage Determinations (LCD's) list specific test CPT codes, as well as the ICD-9 codes (diagnosis codes), that Medicare will cover when they are reasonable and necessary for the diagnosis or treatment of the ICD-9 codes listed. ICD-9 codes supporting medical necessity must be included on the requisition form. The diagnosis must be present for the procedure to be paid and there must be documentation within the patient's medical record. Information on LCD's may be obtained at the Wisconsin Physician Service (Medicare Part B carrier for Wisconsin) Web site. Reflex Testing Reflex testing occurs when initial test results are positive or outside normal parameters and indicate that a second related test is medically appropriate. This WSLH Web site, /compliance/medicare/wslh_reflex.dotincludes a list of the reflex tests that are performed when appropriate. We will bill Medicare using the CPT codes listed in the table on our Web site. Reimbursement will be either the Medicare fee or the WSLH fee, whichever is less. Panels Panels are bundles of tests ordered by physicians as a single unit using a single check mark on a laboratory requisition form. Physicians may also order WSLH panel components separately. Please call the laboratory for testing limitations and instructions for submission (800-862-1013). Panels, and their individual tests, are listed on this WSLH Web site, /compliance/medicare/wslh_panels.dot. Medicare CPT Codes and reimbursement amounts are also listed at the website. Reimbursement will be either the Medicare fee or the WSLH fee, whichever is less. Additional Test Information The WSLH annually publishes a clinical testing Fee Schedule that lists our clinical tests, the Test Code, the test price and the CPT codes used to bill Medicare. The WSLH Fee Schedule is available online in our publications section - /publications/index.dot#fee_schedule. In addition, printed copies may be obtained by calling WSLH Customer Service (800) 862-1088 or (608) 265-2966. If you would like the Medicare Reimbursement rate for any of our tests, please call Customer Service at the numbers listed above. Note: Medicaid reimbursement will usually be equal to, or less than, the Medicare reimbursement. The WSLH also publishes a Reference Manual, which lists all clinical tests including information about the use of each test. The Reference Manual is available in an online form. In addition, printed copies may be obtained by calling WSLH Customer Service (800) 862-1088 or (608) 265-2966. Appropriate test use and ordering may be discussed with the WSLH Physician Clinical Consultant, Dr. Daniel Kurtycz. He can be reached by email at mailto:dkurtycz@facstaff.wisc.eduor calling (608) 262-3911 and leaving a message with the administrative staff for Dr. Kurtycz to return your call. Please don't hesitate to contact me at (608) 265-3537 if you have any questions. Sincerely, Marci Polyak |