Beth Israel Deaconess Medical Center
Laboratory Manual
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Beth Israel Deaconess Medical Center Laboratory Manual |
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I. Overview
Third party payers have become increasingly firm in their requirements for medical justification for use of clinical laboratory tests in outpatients.
In particular, as stated in a recent Federal Register publication:
"The OIG (Office of the Inspector General) takes the position that a physician who orders medically unnecessary tests for which Medicare reimbursement is claimed may be subject to civil penalties." (Federal Register Vol 62, No. 41 March 3, 1997; also: Medicare Compliance Program for Clinical Laboratories from the HHS Office of the Inspector General, February 1997)
Medicare in particular
requires ICD-9 codes for justification of certain individual laboratory tests. Except for a small number
of panels, Medicare also requires that tests be ordered individually, rather
than in groups, to further confirm medical intent and necessity. In addition,
our local Massachusetts Medicare carrier (Associated
Hosptial Services), requires specific ICD-9 justification for several
commonly ordered tests:
(click on the test for
more information, including ICD-9 codes that support medical necessity)
Alpha-Fetoprotein (AFP)
CA125
CA 15-3/CA 27.29
CA 19-9
Blood Counts (CBC and individual cell counts)
Blood Glucose Testing
Carcinoembryonic Antigen (CEA)
Collagen Crosslinks, Any Method (N-Telopeptide)
Culture, Bacterial, Urine
Digoxin
Flow Cytometry
Gamma Glutamyl Transferase (GGT)
Glycated Hemoglobin/Glycated Protein (Hemoglobin
A1c, Fructosamine)
Hepatitis Panel
Human Chorionic Gonadotropin (hCG)
Human Immunodeficiency Virus Testing (Diagnosis)
Human Immunodeficiency Virus Testing (Prognosis
Including Monitoring)
Iron Studies (Iron, TIBC, Transferrin, Ferritin)
Lipids (Total Cholesterol, LDL Cholesterol, HDL
Cholesterol, Triglycerides)
Molecular Diagnostics (Factor V Leiden, Prothrombin
Mutation, etc)
Partial ThromboplastinTime (PTT)
Prostate Specific Antigen (PSA)
Prothrombin Time (PT)
Reticulocyte counts
Thyroid Testing (TSH, T4, Uptake, Free T4)
II. BIDMC policies regarding documentation
A. Every order for laboratory tests must have an ICD-9 code justifying the reason for ordering the test(s). This rule applies regardless of third party payer.
B. In addition, orders for glucose, prothrombin time, lipid panel (or individual constituents), thyroid panel (or individual constituents), PSA, urine culture, digoxin level, glycated hemoglobin/glycated protein, serum iron studies, reticulocyte counts, immunoassay for tumor antigen, partial thromboplastin time, and molecular diagnostics must have recorded the ICD-9 code justifying the test. This rule applies regardless of third party payer.
The code should be recorded in the box on
the requisition next to the name of each of these tests.
For Medicare patients only: In order for Medicare to pay for the above-named lab tests, the ICD-9 code should be chosen from the Medicare list which supports medical necessity and must be consistent with documentation that is in the patients medical record . The complete list of such codes is contained in this publication.
If the ICD-9 code chosen is not included
in the Medicare list of codes supporting medical necessity, the
patient must sign a Medicare Advance
Beneficiary Notice (ABN), acknowledging the lack of Medicare
coverage for payment of the test.
C. The processing of tests ordered with
incomplete requisitions may be delayed until the requisition is properly
filled out.
Incomplete requisitions include those which are missing:
The responsible physicians name
The visit ICD-9 code
The ICD-9 code for a specified test where
this information is required.
A signed Medicare
Advance Beneficiary Notice , where required.
The clinical laboratories will make reasonable efforts to contact the provider and unit, including faxing the incomplete requisition to the site.
Revised/reviewed 9/16/2009