Wiki Independent Laboratory Billing Place of service code

[AuditingAutumn]

Hello! We are an independent lab running lcms(80307) and definitive(G0480-G0483) billing for urine collected at the facility the patient is receiving care from and sent to us. United Healthcare (UHC) just started denying our claims for box 24B and box 32. We have always billed with POS 81 in box 24B but they are now denying saying "The place of service for an independent laboratory must show the place where the sample was taken; based on the information provided on the HCFA 1500 box 24B and box 32 and the medical records submitted, we are unable to verify where the sample was obtained."
This is only happening with UHC. All the other commercial carriers have no issue paying our claims after the review of medical records.
Is anyone familiar with this change? Are they correct? and will other payers be moving to this rule?

Any guidance is very much appreciated.

 

[karamac]

So my guess would be that these patients are in some level of substance abuse treatment, correct? UHC is denying these claims because most likely the patient is in "inpatient" status for that date of service, meaning you would then correctly per Medicare (UHC follows Medicare guidelines) bill the place of service as where the specimen was collected, rather than where the service was performed. I have had multiple clients receive these denials since June 1.

Here's the bad news, once you re-submit that claim, you are most likely going to be denied because the laboratory testing is bundled into the facilities payment for services and is not a separately billable physician service. Some levels of substance abuse treatment can be billed on the physician fee schedule.

Additional issues you will come across in Substance Abuse----As an independent laboratory billing for services in the substance abuse treatment space is very complex. Not all levels of treatment will be considered reimbursable by the patient's insurance. The biggest areas of issue- sober living, home monitoring are not a covered service under a patient's medical benefit. The ordering provider needs to be a MD/DO/PA-C or Advanced Practice Nurse (APRN, CFP, etc.). Just because a provider has an NPI does not mean that they have the scope of practice to order a laboratory test, especially drugs of abuse. So State laws need to be researched and reviewed before a provider is allowed to refer specimens to a laboratory.

The easiest solution is to make adjustments to you requisition form to capture with a check box the level of treatment the patient is in. The ones that we place on client requisitions are Inpatient, Detox, PHP, IOP, Outpatient, Sober Living. That way your accessioning team can flag all of the non-covered specimens- Inpatient, Sober Living, IOP, and potentially PHP and have a discussion with the client.

To successfully navigate servicing this market, you need to partner directly with the treatment facility and have full transparency into their contracts, and how they are billing the treatment services.

https://www.cms.gov/Outreach-and-Ed...k-MLN/MLNMattersArticles/downloads/MM7631.pdf

 

[AuditingAutumn]

thank you. More

Thank you for your response to my post. I have additional issues as well that you might be able to help me with.

I have a client whom is a multi-specialty group of physicians but has a clia for independent laboratory and shares a location within a facility(21 & 22). This client is testing for the lcms and definitive drug screens that are collected by the facility the patient is receiving treatment from. The facility and doctors group share an address but have separate NPI numbers... The doctors group is also billing for initial hospital visits, subsequent hospital visits, etc... The requisition says the referring is the facility.
(hopefully that wasn't too confusing)
With that information: This would indicate that the doctors group with the CLIA should be billing these drug screens, have the POS code in box 25B be 21 or 22 (depending on the Level of care the patient was receiving from the facility), box 32 should have the facilities address in it, and what should be in 24J: The NPI of the lab director that is listed on the CLIA as the director or the doctors groups NPI?
Also, who's name in box 31: The lab director's name or the physician's name?

I just covered a lot and I hope that wasn't too confusing. We haven't had an issue in the past but now BCBS is denying all labs the group bills with POS 81 and the group listed in box 32, stating taxonomy does not match...

 

[Cavalier40]

So my guess would be that these patients are in some level of substance abuse treatment, correct? UHC is denying these claims because most likely the patient is in "inpatient" status for that date of service, meaning you would then correctly per Medicare (UHC follows Medicare guidelines) bill the place of service as where the specimen was collected, rather than where the service was performed. I have had multiple clients receive these denials since June 1.

Here's the bad news, once you re-submit that claim, you are most likely going to be denied because the laboratory testing is bundled into the facilities payment for services and is not a separately billable physician service. Some levels of substance abuse treatment can be billed on the physician fee schedule.

Additional issues you will come across in Substance Abuse----As an independent laboratory billing for services in the substance abuse treatment space is very complex. Not all levels of treatment will be considered reimbursable by the patient's insurance. The biggest areas of issue- sober living, home monitoring are not a covered service under a patient's medical benefit. The ordering provider needs to be a MD/DO/PA-C or Advanced Practice Nurse (APRN, CFP, etc.). Just because a provider has an NPI does not mean that they have the scope of practice to order a laboratory test, especially drugs of abuse. So State laws need to be researched and reviewed before a provider is allowed to refer specimens to a laboratory.

The easiest solution is to make adjustments to you requisition form to capture with a check box the level of treatment the patient is in. The ones that we place on client requisitions are Inpatient, Detox, PHP, IOP, Outpatient, Sober Living. That way your accessioning team can flag all of the non-covered specimens- Inpatient, Sober Living, IOP, and potentially PHP and have a discussion with the client.

To successfully navigate servicing this market, you need to partner directly with the treatment facility and have full transparency into their contracts, and how they are billing the treatment services.

https://www.cms.gov/Outreach-and-Ed...k-MLN/MLNMattersArticles/downloads/MM7631.pdf

We are having the same issue. In most cases the patient is not at an inpatient facility and never are the specimens collected at sober living or home monitoring. They are all collected at the PHP, IOP or OP level of care. They are ordered and reviewed by an MD and yet they are still getting denied.

I am having difficulty understanding why a definitive test that requires a LC/MS machine is bundled into a facility charge when the facility has nothing to do with performing the test. We are asked to confirm positive presumptive samples and when there has been suspicion of use. The business model of the lab is to bill and collect from insurance, does this mean I now need to charge per sample at our facilities? Can someone shed some light on this?

 

[karamac]

Substance Abuse and Laboratory Billing...

We are having the same issue. In most cases the patient is not at an inpatient facility and never are the specimens collected at sober living or home monitoring. They are all collected at the PHP, IOP or OP level of care. They are ordered and reviewed by an MD and yet they are still getting denied.

I am having difficulty understanding why a definitive test that requires a LC/MS machine is bundled into a facility charge when the facility has nothing to do with performing the test. We are asked to confirm positive presumptive samples and when there has been suspicion of use. The business model of the lab is to bill and collect from insurance, does this mean I now need to charge per sample at our facilities? Can someone shed some light on this?

I completely empathize with your frustration, as I cannot begin to tell you how many clients I have that are now on pre-pay review for this exact scenario. Just because the patient is being seen at PHP, IOP, or even OP does not necessarily mean that the laboratory testing is a separately billable service on the Physician Fee Schedule. If your treatment facility partner's contract with the payer has them billing the services on a per diem basis, or on a UB-04 then any laboratory testing whether it is urine, chemistry, genetics could be bundled into the facilities payment for the treatment of that patient.

Clinically, you should be aware that there are sweeping changes to the coverage policies for urine drug testing in the setting of substance abuse. There are multiple commercial payers, as well as state medicaids that are determining that definitive testing in this setting is experimental and therefore not covered. This is due to widespread overutilization in not just the frequency of testing by date of service, but also the number of drug classes per patient. Based on your comment on confirmation of presumptive positives, it would appear that this is not the case but a few other things that you may want to look into:

Are you billing the patient's medical benefit or their behavioral health benefit?
Does the testing need to be prior authorized?
Does your requisition form have panels or does the provider choose the testing by drug class? NO PANELS- payers will deny just based on your requisition form listing a panel.
What denial code are you receiving?
Are you being asked for medical records to support the services, and are you getting them.. (you need to - and to dispel a myth- you can collect medical records from a substance abuse treatment facility for the purpose of defending a billed service- including from Part 2 participating facilities.)
Is the provider signing the requisition?
Is the MD ordering seeing the patient on the date the drug screen is ordered? (The payers are running edits that compare your date of service, with a billed service of the ordering provider.)


Feel free to give me a call if you would like to discuss further, sometimes it is better to walk thru what you are seeing on the phone rather than in the forum.

 

[karamac]

Confusing .. nah....

Thank you for your response to my post. I have additional issues as well that you might be able to help me with.

I have a client whom is a multi-specialty group of physicians but has a clia for independent laboratory and shares a location within a facility(21 & 22). This client is testing for the lcms and definitive drug screens that are collected by the facility the patient is receiving treatment from. The facility and doctors group share an address but have separate NPI numbers... The doctors group is also billing for initial hospital visits, subsequent hospital visits, etc... The requisition says the referring is the facility.
(hopefully that wasn't too confusing)
With that information: This would indicate that the doctors group with the CLIA should be billing these drug screens, have the POS code in box 25B be 21 or 22 (depending on the Level of care the patient was receiving from the facility), box 32 should have the facilities address in it, and what should be in 24J: The NPI of the lab director that is listed on the CLIA as the director or the doctors groups NPI?
Also, who's name in box 31: The lab director's name or the physician's name?

I just covered a lot and I hope that wasn't too confusing. We haven't had an issue in the past but now BCBS is denying all labs the group bills with POS 81 and the group listed in box 32, stating taxonomy does not match...

Full Disclosure- Not a Healthcare Attorney- So I may be totally confused.. but that's ok we will figure it out. I HAVE ALOT OF QUESTIONS and probably best to give me call and I can walk thru it with you. My questions are going to relate to how the laboratory is set up from a business perspective , what type of "facility" this is. How you set up a laboratory within a physician's practice or group is very, very complicated, especially when it can involve stark law implications. To try and keep this simple..

The "group" you mention is not an independent laboratory-- they are a physicians group- so that is why 81 is a no go. Which is why this goes back to how the laboratory is set up, and CREDENTIALED with the payer? Are you OON as a provider with BCBS as the Lab, if so you need to get a non-par number to bill? Just because a physician group shares a space with a facility does not mean that their CLIA or business structure will permit them accepting specimens from technically- a non-related business entity. Disclosure, I am not a healthcare attorney, but it is ESSENTIAL that a laboratory that is performing definitive testing in this day and age have one- and one that is highly experienced in laboratory issues and challenges.

Hypothetically, we sometimes see this scenario- and this may or may not be applicable to your situation but--If a patient is an inpatient, PHP, Detox etc. that laboratory testing is going to be bundled into the facilities fee, so your lab that is not technically related to that facility (separate NPI's, Tax ID's) should have a reference laboratory agreement with the facility, the facility pays you directly for the work at a fee no lower than 80% of the medicare fee schedule (this is where you need the attorney, because I am not one) and then the facility bills the carrier for the lab services, disclosing that the work was performed by another laboratory (90 modifier). In my experience, this usually does not work, especially based on the fee's as it relates to definitive testing, one definitive test can be more than a hospital is paid per day for a patient in treatment.


I know who knew laboratory could be sooooo complicated....

Please feel free to give me a call...

 

[Mb1369]

Independent Laboratory Billing POS 81

Hello, I am in the same boat. We are an independent anatomic pathology laboratory billing with POS code 81. We bill to all types of insurance and we have one insurance in Florida that is telling us to bill with the POS code for where the specimen was taken. We have a call with them to try and explain ourselves but interestingly enough in doing research of this on CMS I cannot find the transmittal that deals with the outcome. Transmittal 2679 is the revised and clarified POS instructions but CMS left out the pathology and laboratory billing in this transmittal and states it will be in a future change request but I cannot find that change request. Its a dead end. Does anyone have any input on where I can find such information to prove this to this insurance on our call tomorrow?
thank you in advance for any help.

 

[karamac]

Hello, I am in the same boat. We are an independent anatomic pathology laboratory billing with POS code 81. We bill to all types of insurance and we have one insurance in Florida that is telling us to bill with the POS code for where the specimen was taken. We have a call with them to try and explain ourselves but interestingly enough in doing research of this on CMS I cannot find the transmittal that deals with the outcome. Transmittal 2679 is the revised and clarified POS instructions but CMS left out the pathology and laboratory billing in this transmittal and states it will be in a future change request but I cannot find that change request. Its a dead end. Does anyone have any input on where I can find such information to prove this to this insurance on our call tomorrow?
thank you in advance for any help.

So I may be confused, but which change request are you referencing, the CMS transmittal that discusses inpatient vs. outpatient services. If this is a commercial payer, they just may be confused- period. This happens quite often, and would recommend having and documenting the discussion and what their guidance is. Are you in-network or out-of-network?