by Jared Staheli
July 10th, 2015
Profiles are specific groupings of blood chemistries that enable physicians to more accurately diagnose their patients’ medical problems. While the component tests in automated profiles may vary somewhat from one laboratory to another, or from one physician’s office or clinic to another, in order to develop appropriate payment amounts, contractors group together those profile tests that can be performed at the same time on the same equipment. The carrier or FI must group together the individual tests in the profile when billed separately and consider the price of the related automated profile test. Payment cannot exceed the lower of the profile price or the totals of the prices of all the individual tests. (This rule is applicable also if the tests are done manually.) The profile HCPCS code and each individual test is priced at the lower of the billed charge or the fee amount; and payment is made at the lower of the profile/panel price or the total of the prices for all covered components.
Payment is made only for those tests in an automated profile that meet Medicare coverage rules. Where only some of the tests in a profile of tests are covered, payment cannot exceed the amount that would have been paid if only the covered tests had been ordered. For example, the use of the 12-channel serum chemistry test to determine the blood sugar level in a proven case of diabetes is unreasonable because the results of a blood sugar test performed separately provide the essential information. Normally, the payment allowance for a blood sugar test is lower than the payment allowance for the automated profile of tests. In no event, however, may payment for the covered tests exceed the payment allowance for the profile.
However, the carrier prices and pays the 1-22 automated multi-channel chemistry tests tested in §90.2 at the lowest possible amount in accordance with §90.3.