Negotiated Rulemaking Implementation

120.1 - Negotiated Rulemaking Implementation (Rev. 1769, Issued: 07-10-09, Effective/Implementation: 07-31-09) The following requirements apply to service providers: • The date of service should be reported as the date of specimen collection. • The person obtaining the specimen must furnish the date of collection for the specimen to the entity billing Medicare. • For specimen collections that span more than a 24-hour period, the date of service should be reported as the date the collection began. • For laboratory tests that require a specimen from stored collections, the date of service should be defined as the date the specimen was obtained from the archives. • If a situation occurs that does not correspond to the two situations described, the A/B MAC (A) or (B) will submit the question to the RO with the appropriate documentation. The RO will contact the Division of Supplier Claims Processing in CMS, which will serve as the point of contact. Matching of Diagnosis to Procedure During claims processing and adjudication, the A/B MAC (A) or (B) adheres to the following: • If there is a LMRP or NCD for one or more of the services included on the claim, the A/B MAC (A) or (B) reviews all of the diagnosis codes in making a determination regarding medical necessity of the service. • Even though a claim matches diagnosis to procedure in accordance with an NCD, other rules of adjudication may apply, which could result in denial. • Diagnoses are required on all claims. Physicians Reporting Diagnosis Codes When A Diagnostic Test Is Ordered Section 4317 of the Balanced Budget Act of 1997 provides, with respect to diagnostic laboratory and certain other services, that “if the Secretary (or A/B MAC (A) or (B) of the Secretary) requires the entity furnishing the services to provide diagnostic or other medical information to the entity, the physician or practitioner ordering the service shall provide that information to the entity at the time the service is ordered by the physician or practitioner.” A laboratory or other provider must report on a claim for Medicare payment the diagnostic code(s) furnished by the ordering physician. In the absence of such coding information, the laboratory or other provider may determine the appropriate diagnostic code based on the ordering physician’s narrative diagnostic statement or seek diagnostic information from the ordering physician/practitioner. However, a laboratory or other provider may not report on a claim for Medicare payment a diagnosis code in the absence of physician-supplied diagnostic information supporting such code. Clarification of the Use of the Term “Screening” or “Screen" The final rule clarifies that effective February 21, 2002, the use of the term “screening” or “screen” in CPT code descriptor does not necessarily describe a test performed in the absence of signs and symptoms of illness, disease or condition. A/B MACs (A) and (B) do not deny a service based solely on the presence of the term “screening” or “screen” in the descriptor. Tests that are performed in the absence of signs, symptoms, complaints, personal history of disease, or injury are not covered except when there is a statutory provision that explicitly covers tests for screening as described. If a person is tested to rule out or to confirm a suspected diagnosis because the patient has a sign and/or symptoms, this is considered a diagnostic test, not a screening test. A/B MACs (A) and (B) have discretionary authority to make reasonable and necessary scope of benefit determinations.