by Jared Staheli
July 10th, 2015
All test codes should be processed and stored in history as they are submitted. That is, if tests are submitted as individual CPT codes together and paid as a panel (see §90), the claim history data will reflect the individual codes and the panel used in pricing. All tests must maintain their identity as billed.
Prior to January 1, 1998, automated panel codes were adjudicated only on a line-by-line basis with application of the correct coding initiative (CCI) edits for duplicate detection.
Beginning with processing date January 1, 1998, when individual automated test codes are received, carriers and FIs do not combine them into panels for processing. The only instance in which they should be panel codes is when they are coded as such on the claim.
Panels must be processed line by line, and must be compared to other claims with automated test panels and/or single laboratory HCPCS codes in the current processing cycle, plus previous paid/processed claims. Therefore, any and all automated tests must be paid as a panel, but still retain their individual identity for duplicate detection and medical necessity review.
Carriers and FIs
1. Deny Duplicates. Deny duplicate services detected within the same processing cycle or stored in an automated history file. Consider claims that match on the following items as duplicates
a. The service was performed by the same provider,
b. For the same beneficiary, and
c. For the same date of service.
2. Medical Necessity. Determine medical necessity. This process permits the identification of CPT codes subject to local medical review policies.
3. Process Claims. The processes shown below (A-K) should be followed to price and pay claims for automated panels (as defined in HCPCS) and individual tests. This does not replace or abridge any current procedures in place concerning the adjudication of claim. This is a general procedure for combining these services to attain the lowest pricing outcome. This display is an example only. System maintainers have the flexibility to vary these procedures as long as they attain the same result.
A. Unbundle all panels to single lines representing individual automated multi-channel chemistry (AMCC) tests, and identify duplicate tests within the claim. On concurrently processed claims, determine the total amount payable based on the combination of all AMCC tests billed by the same laboratory, for the same beneficiary, and for the same date of service.
B. Check history for laboratory AMCC services provided by the same provider, to the same beneficiary, on the same day. Unbundle any panels. Identify duplicate services. Aggregate all nonduplicate services for pricing (include the submitted charge and paid amounts for both individually or paneled billed claims). If a single organ disease panel or a single chemistry panel contains the only AMCC test claims for that date of service, adjudicate as billed.
C. Compare each line’s submitted charge to the fee schedule for that code (including automated tests retrieved from history).
D. Sum the comparisons of the line by line.
E. Obtain the fee for all AMCC tests as a panel including all services in history. If organ disease (OD) panels are involved, this amount will include fees for nonautomated tests included in the OD panel.
F. Carry forward the lesser of items D or E.
G. For steps A-C above, include the following calculations to price the claim by locality, using the fee schedule amount for each locality, when one or more test has been referred to another laboratory for processing:
Use the total number of allowable AMCC tests (both referred and nonreferred) to calculate the amount payable for each test. For example, if three tests are performed within the local carrier’s jurisdiction, and two are referred to another laboratory for processing, first determine the amount payable for the five tests in each payment jurisdiction. Divide the total fee schedule amount for all tests being priced by the total number of allowable AMCC tests (in this example, five tests). The result is the unit price for each test. Multiply this result by the total number of AMCC tests performed within each pricing jurisdiction. (In this example, three tests were performed in jurisdiction 1 and two tests were performed in jurisdiction 2). Repeat this process for each pricing jurisdiction. In this example, there are two pricing jurisdictions. In jurisdiction 1, the amount payable is calculated by dividing the total fee schedule amount for jurisdiction 1 by five, and multiplying the result by three. Similarly, the amount payable for jurisdiction 2 is calculated by dividing the total fee schedule amount for jurisdiction 2 by five, and multiplying the result by two. Sum the two results (i.e., jurisdiction 1 amount + jurisdiction 2 amount). Compare this calculated amount to the submitted charges for the AMCC tests to determine the amount payable. (The amount payable is the lower of the fee schedule amount versus the submitted charges.)
H. Carry forward the lesser of the fee schedule amount versus the submitted charges, as determined in item G.
I. Subtract from item H any previous laboratory AMCC test (individual or paneled) or organ disease panel containing automated test payments. If nothing is payable on the claim, allow it with no payment.
J. The amount payable is the total payable based on the combination of current and previously processed claims, less the total amount paid on the previous claim(s).
K. If a claim is a CLIA reject from the CWF, Recycle that claim through the payment process to recalculate payment.
(NOTE: These calculations are provided as an example only. Carriers and standard system maintainers have the flexibility to vary these procedures as long as they attain the same result.)
If none of the AMCC tests have been referred to another laboratory for processing, carriers should exclude item G in calculating the amounts payable for individual AMCC tests and AMCC panels.