The Centers for Medicare & Medicaid Services (CMS) is reminding providers to be careful when submitting laboratory blood count fees, noting that most denials are preventable.
For example, in 2017, CMS said the Medicare fee-for-service improper payment rate for blood counts was 19.2 percent with projected inaccurate payments of $56.6 million. Improper payments resulted from:
· Insufficient documentation - 89 percent
· Incorrect coding - 8.3 percent
· No documentation - 2.7 percent
Providers must meet the following conditions for reimbursement:
· The physician/NPP who is treating the beneficiary must order the blood counts. The physician/NPP is the one who furnishes a consultation or treats a beneficiary for a specific medical problem, and who uses the results in the management of the beneficiary’s specific medical problem. Tests not ordered by the physician or NPP treating the beneficiary are not reasonable and necessary.
· Providers must order all x-rays, laboratory tests, and other diagnostic tests for the treatment of the individual beneficiary. Criteria to establish medical necessity for blood counts must be based on beneficiary-specific elements identified during the clinical assessment and documented by the clinician in the beneficiary’s medical record. Laboratory tests – blood counts used for routine screening of beneficiaries without regard to their individual need usually are not covered by the Medicare Program, and therefore are not reimbursed.
· The physician/NPP who ordered the test must maintain documentation of medical necessity in the beneficiary’s medical record.
· Entities submitting a claim must maintain documentation received from the ordering physician/NPP.
Prevent denials by reviewing CMS's Provider Compliance Tips for Laboratory Tests – Blood Counts Fact Sheet, which was released last year to provide coverage and documentation requirements.
