Pathology/Lab Coding Alert

Pathologists may choose to participate.

Whether pathologists in your practice are new or existing Medicare providers, the following pointers can smooth the rough spots to facilitate successful participation.

Check out the following tips for “Medicare 101,” courtesy of Arlene Dunphy, CPC, and Michele Poulos of NGS Medicare, during a recent Part B payer’s webinar.

Decide Whether to Participate or Be Non-Par With Medicare

“Participating providers have an agreement on file to accept assignment on all Medicare patients,” Dunphy said during the presentation. “They accept the Medicare-approved charge amount and collect only the deductible and coinsurance amounts for covered Medicare services.”

Participating providers collect a higher amount than non-par providers because they aren’t subject to the limiting charge, she added. Non-participating providers face a limiting charge and collect 95 percent of the fee schedule amount.

Grasp Basic Payment Scheme

Traditional Medicare pays 80 percent of the allowed charges, and the patient makes a 20 percent copayment, Dunphy said. A deductible and coinsurance apply in most cases, and patients pay a monthly premium.

Medicare’s deductible this year is $183, which means the first $183 of approved charges for medical expenses are the patient’s responsibility, she said.

Prepare for Regular Fee Changes

Medicare sets its fees through annual fee schedules, but what you collect this year may change when the new year rolls around. “The fee schedule changes year to year and is approved by Congress,” Poulos said.

Two schedules: Most pathology procedures are paid on the Medicare Physician Fee Schedule. On the other hand, most laboratory procedures appear on the Clinical Laboratory Fee Schedule. Both schedules have annual adjustments.

Some years, fees will go up for particular procedures, but the opposite has been known to happen as well, so keep a close eyes open every year when the new versions come out.

Abide by LCDs and NCDs

The regional Medicare Administrative Contractors (MACs) publish local coverage determinations (LCDs) that outline the specific information needed to submit a claim, Poulos said. “The LCD covers the indications andlimitations of treatment, the primary and secondary ICD-10 codes supporting medical necessity, documentation requirements, utilization guidelines, frequency, and billing guidelines,” she said. Therefore, it’s in your best interest to know the LCDs for the services you perform most often very well.

Some procedures have National Coverage Determinations (NCDs). Like LCDs, these guidelines inform you about coverage rules, medical necessity, frequency limitations, etc., but they apply to Medicare providers throughout the country.

Be Patient For Claims Resolution

Although sometimes you’ll collect for your claims quickly, that isn’t always the case, and if payment takes more than a few weeks, you shouldn’t just resubmit claims and hope to get paid faster.

“Allow 29 days for paper claims and 14 days for electronic claims to be processed,” Dunphy said. “Electronic claims submitters should check your EDI validation report to verify claims were received and accepted, and check your software system to verify claims are not set up for automatic rebill every 30 days.”