ACT Questions and Answers - July 15, 2020

The following questions and answers (Q&As) are cumulative from the Part B Ask the Contractor Teleconference (ACT) that were specific to Diagnostic Lab and X-Rays. Some questions have been edited for clarity and answers may have been expanded to provide further details. Similar questions were combined to eliminate redundancies. If a question was specific just for that office, Noridian addressed directly with the provider. This session included Medicare program updates, pre-submitted questions, and questions posed during the event.

  • Special Lab and X-Ray reminders at Noridian’s Browse by Specialty pages under Laboratory or Radiology
    • Physician Orders for Diagnostic Lab Tests Article
  • Validity Tests under Special Edition (SE) 18001
  • New Advance Beneficiary Notice (ABN) effective January 1, 2021 (revised from August 30, 2020). Form found on the CMS website at ABN Form.

Q1. In lab claims, is the rendering NPI indicated in Item 24J?
A1. Lab claims are not required to have Item 24J (electronic loop/segment equivalent) filled out. The ordering physician's name and NPI is located in Items 17 and 17B. Read more at under Section of the CMS Internet Only Manual (IOM) 100-04, Chapter 16 - Laboratory Services (PDF).

Q2. When the interpretation is performed via teleradiology, where is the interpreting radiologist identified on the claim?
A2. Item 32 of the CMS-1500. The POS is where the beneficiary received the technical component (face-to-face encounter) and the interpreting physician reports the address and ZIP code of the his/her location with complete name, address and NPI. The provider must follow licensing requirements and interpretation must occur within the U.S. See Sections 150.A and E at Internet Only Manual (IOM) Publication 100-04, Chapter 13.

Q3. Can Noridian provide guidance to the Opt-Out providers that refer specimens to lab?
A3. Opt-Out providers that refer lab specimens must enroll with Noridian Medicare via the simple CMS-855O enrollment form found on the Noridian Forms page. All referring providers should read the important information on the Noridian webpage under Browse by Specialty at JE Laboratory or JF Laboratory that includes the “Dear Ordering/Referring Physician Letter” and the “Surgical Pathology Medical Documentation Letter” found in the Educational Resources.

Q4. How should we bill surgical pathology for units that exceed CMS’ Medically Unlikely Edit (MUE) per day guidelines? Can we bill modifier 76 on other lines?
A4. Do not bill modifier 76 in MUE cases. If the number of units is over the MUE value, the Medicare Claims Processing System denies all units and the second line is not accepted. In the pathology CPT 88305 example, MUEs were 16 and 17 was billed. Both line denials may be appealed with supporting documentation. Noridian cannot change the MUEs mandated by the National Correct Coding Initiative (NCCI).

Q5. How does COVID-19 impact Protecting Access to Medicare Act (PAMA) of 2014 reporting? Can we anticipate a delay in reporting due to the COVID-19 efforts?
A5. Yes. CMS provided information regarding the delay in the July quarterly clinical laboratory updates with change request (CR) 11815, published on June 12, 2020. The next data reporting period of January 1, 2022 through March 31, 2022 is based on the original data collection period of January 1, 2019 through June 30, 2019.

Q6. For CPT codes with supervision rules, is the attending or supervising provider indicated on the claim for a Hospital Outpatient facility? For example, Pacemaker interrogations require direct supervision for the technical portion.
A6. The physician or other qualified health care professional can provide direct supervision for CPT 93296 (“interrogation device (single dual or multiple lead) pacemaker system……; technician review, technical support and distribution of results”). A reminder that the supervising provider (also signing the documentation), should be reflected as the billing provider. During a claim review, if the performing and signing physician do not match the billing provider, the claim will deny.

Q7. Provider mistakenly sent incorrect diagnosis for the lab order and the lab’s claim denies. How do providers work with the lab to send in a corrected claim, with the correct diagnosis, when the lab refuses?
A7. First, before the orders are sent, setting an office policy to verify correct diagnosis codes are sent to the lab. Work with the lab on the best process to submit a corrected claim when an error occurs. If they still refuse, the ordering provider may provide the beneficiary a copy of their medical records (showing their diagnosis) and help the beneficiary file an appeal using their Medicare Summary Notice (MSN). Since appeals only requests documentation from the lab and not the ordering provider, this may be a good solution.

Q8. Is CMS starting the prior authorization of nuclear stress tests (e.g., CPT 78452) on January 1, 2021?
A8. No. However, CPT 78452 and other codes for are part of the Appropriate Use Criteria (AUC) for Advanced Diagnostic Imaging requirements in 2021. This includes computed tomography (CT) and positron emission tomography (PET) scans, nuclear medicine and magnetic resonance imaging (MRI). The information can be found on the CMS website at AUC Program that includes the Appropriate Use Criteria for Advanced Diagnostic Imaging – Fact Sheet (PDF).

Q9. When the lab is running Vitamin D levels, why do providers need to support medical necessity? Is there guidance in the absence of signs and symptoms, but patient is COVID-positive? The doctor’s found evidence of low vitamin A and trying to figure out if this is something they should make as a required test. 
A9. Medicare does not pay for research and needs to have evidence of medical necessity. There needs to be a reason why the x-ray was ordered and rendered. Possible examples might be checking for fractures (broken bones), to spot pneumonia or a mammogram ordered to look for breast cancer. Order and testing results alone do not support medical necessity. Per Medicare Program Integrity Manual, Publication 100-08, Chapter 3, Section “because the provider selected for review is the one whose payment is at risk, it is this provider who is ultimately responsible for submitting, within the established timelines, the documentation requested by the MAC.” Read more under the Social Security Act, Title XVIII at Section 1833 and Section 1862.

Q10. If a provider’s office is handling just the specimen (not the testing) and are not part of a lab, are any of those codes compliant and billable to Part B? If so, what would be the appropriate code?
A10. If an office is drawing a specimen, then bill CPT 99211 could be billed and then send the specimen to the lab.

Q11. Our oncology clinic is performing the technical portion of cytogenetic testing and wants to send the result to our PhD and have him or her provide the interpretation. It’s my understanding PhDs cannot bill for professional work.
A11. Your understanding is correct that PhDs cannot bill for professional work or the interpretation of the testing. If the clinic is performing a lab specimen review, it is a part of the practice expense of the code. The interpretation could possibly be incident to the physician who overlooks the results. Please be aware that the National Coverage Determination (NCD) 190.3 Cytogenetic Studies added ICD-10 C884 to discretionary coverage effective October 1, 2019.

Q12. Does Noridian have a policy to clarify CPT 75571 (CT, heart)? Other Medicare Administrative Contractors (MACs) have articles and Local Coverage Determinations (LCDs) indicating this code alone is not payable due to not meeting medical necessity.
A12. Agree that Noridian does not have a policy. Medicare does have pricing in the system for diagnostic testing. If it’s used as a screening test, it will not allow.

Q13. Can you please explain more on the Appropriate Use Criteria (AUC)? Is CMS delaying the start date of the program with these specific procedure codes?
A13. At this time, there is no expectation that CMS will delay this program effective January 1st, 2021. We do encourage providers to use this year to learn, test and prepare for the AUC program. AUC consultation will be required for all advanced diagnostic imaging services. Please watch our website for upcoming educational webinars that will be focused on the AUC program. This webinar will be held in either September or October 2020. The following procedure codes will use the AUC program:

Magnetic Resonance Imaging/Magnetic Resonance Angiography
70336, 70540, 70542, 70543, 70544, 70545, 70546, 70547, 70548, 70549, 70551, 70552, 70553, 70554, 70555, 71550, 71551, 71552, 71555, 72141, 72142, 72146, 72147, 72148, 72149, 72156, 72157, 72158, 72159, 72195, 72196, 72197, 72198, 73218, 73219, 73220, 73221, 73222, 73223, 73225, 73718, 73719, 73720, 73721, 73722, 73723, 73725, 74181, 74182, 74183, 74185, 75557, 75559, 75561, 75563, 75565, 76498, 77046, 77047, 77048, 77049

Computerized Tomography
70450, 70460, 70470, 70480, 70481, 70482, 70486, 70487, 70488, 70490, 70491, 70492, 70496, 70498, 71250, 71260, 71270, 71275, 72125, 72126, 72127, 72128, 72129, 72130, 72131, 72132, 72133, 72191, 72192, 72193, 72194, 73200, 73201, 73202, 73206, 73700, 73701, 73702, 73706, 74150, 74160, 74170, 74174, 74175, 74176, 74177, 74178, 74261, 74262, 74712, 74713, 75571, 75572, 75573, 75574, 75635, 76380, 76497 and Single-Photon Emission Computed Tomography  76390

Nuclear Medicine
78012, 78013, 78014, 78015, 78016, 78018, 78020, 78070, 78071, 78072, 78075, 78099, 78102, 78103, 78104, 78110, 78111, 78120, 78121, 78122, 78130, 78135, 78140, 78185, 78191, 78195, 78199, 78201, 78202, 78215, 78216, 78226, 78227, 78230, 78231, 78232, 78258, 78261, 78262, 78264, 78265, 78266, 78267, 78268, 78278, 78282, 78290, 78291, 78299, 78300, 78305, 78306, 78315, 78350, 78351, 78399, 78414, 78428, 78429, 78430, 78431, 78432, 78433, 78434, 78445, 78451, 78452, 78453, 78454, 78456, 78457, 78458, 78459, 78466, 78468, 78469, 78472, 78473, 78481, 78483, 78491, 78492, 78494, 78496, 78499, 78579, 78580, 78582, 78597, 78598, 78599, 78600, 78601, 78605, 78606, 78608, 78609, 78610, 78630, 78635, 78645, 78650, 78660, 78699, 78700, 78701, 78707, 78708, 78709, 78725, 78730, 78740, 78761, 78799, 78800, 78801, 78802, 78803, 78804, 78811, 78812, 78813, 78814, 78815, 78816, 78830, 78831, 78832, 78835, 78999

C8900, C8901, C8902, C8903, C8905, C8908, C8909, C8910, C8911, C8912, C8913, C8914, C8918, C8919, C8920, C8931, C8932, C8933, C8934, C8935, C8936

Here are some useful CMS links:

Q14. What was the reason for the mass adjustment for flow cytometry?
A14. There were ICD-10 diagnoses on the Local Coverage Article (LCA) added at the beginning of the year. These were not added to the editing and caused unnecessary denials. Read more at Noridian’s webpage under Policies at JE Flow Cytometry Article or JF Flow Cytometry Article.

Q15. Can independent labs use HCPCS G2023 for samples self-collected through a drive-thru site? 
A15. No. G2023 (specimen collection for severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) (Coronavirus disease [COVID-19]), any specimen source) is billed when an independent lab sends a trained technician to the patient. To be medically necessary for this sample collection, the method must require some training or skill on the part of the laboratory technician and cannot be conducted by the beneficiary, the beneficiary’s caregiver, or facility staff. If the facility does not have a lab, they could use an outside lab to perform testing of their patients.

The Medicare Claims Processing Manual provides additional guidance on the medical necessity requirements for specimen collection. Specifically, the manual states that “Medicare allows payment for a specimen collection fee when it is medically necessary for a laboratory technician to draw a specimen from either a nursing home patient or homebound patient” and that “the technician must personally draw the specimen.” It also states that this fee will not be paid to anyone who has not extracted the specimen.

Practitioners can be paid for assessment and specimen collection for COVID-19 testing using the level 1 evaluation and management code CPT 99211. Considering the public health emergency, Medicare will recognize this code to be billed for all patients, not just established patients. This approach helps physician practices to operate testing sites during the PHE. See also page 96 of the CMS COVID-19 Document.


            Last Updated Thu, 06 Aug 2020 17:50:55 +0000