Palmetto Launches Diagnostic Services Program

Palmetto GBA launched the first phase of a new program Sept. 1 that is intended to increase the Medicare administrative contractor’s (MAC) accuracy rate for determining reasonable and necessary laboratory and molecular diagnostic services. The Part B Medicare administrative contractor (MAC) for jurisdiction 1 said the new program will allow for more accurate reimbursement of those services that are not listed in the current Centers for Medicare & Medicaid Services (CMS) laboratory fee schedule.

Under the “Laboratory and Molecular Diagnostic Services Program,” Palmetto will:

  • Collect submission data
  • Identify the specific services performed and billed to Medicare
  • Determine coding/billing guidelines to report billed services
  • Determine coverage for new services
  • Determine reimbursement for services within current CMS guidelines

Affected diagnostic services include those that:

  • Require/use more than one CPT® code to identify the service
  • Use the methodology-based “stacking CPT® codes” (83890-83914), micro-array CPT® codes (88384-88386), and cytogenetic CPT® codes (88230-88291)
  • Use a “not otherwise specified” (NOC) code

During this initial phase of the program, providers should make system changes to enter the specific test/assay name into the description field; and begin submitting the test/assay name in the description field in the electronic format at the procedure code level (in the 4010 format for the 837 submission file, enter the information into the 2400 loop in the NTE segment). Palmetto is now accepting coverage decision requests and says it will identify and accept comments to facilitate the process.

Palmetto will begin phase 2 of its program Dec. 1. At this time, the contractor will reject claims submitted without the name of the test/assay in the description field. Claim rejections cannot be appealed and must be resubmitted with the correct information.

Source: Palmetto GBA article, posted online Aug. 31


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