Update nurses on HCFA’s changes to lab tests
New rules take effect in January
Education managers have so many new regulations and requirements to go over with staff that one important change might be overlooked: The Health Care Financing Administration (HCFA) has implemented new rules that require laboratories and health care providers to document that each lab test is medically necessary.
Home care agencies could find themselves trapped in the middle of the foray because if physicians fail to fill out these medical codes, the home care nurses will have to obtain the code.
Starting Jan. 1, 1998, if a physician orders a lab test to be done, the lab slip will have to include a medical code that documents why this test is necessary. If the lab test includes two or more analyses of chemicals (anolytes), then each one of these anolytes will have to be coded even if they’re all part of one test panel.
In the past, physicians have ordered panels with up to 21 anolytes.
Another issue is that some labs are starting to send home care agencies permission slips for patients to sign.
"Three labs have given us permission slips that say, The test you are about to have drawn may not be covered by Medicare or insurance, so you may be responsible for the cost of it,’" says Sally Bryant, RN, agency director of Medical Innovations of Woodbridge, VA, a Medicare home health agency that serves Virginia from Richmond to the northern portion of the state.
Bryant says such notices might frighten patients or at least add to their confusion about what Medicare will cover.
The changes have created some confusion for laboratories, as well. Although HCFA is requiring a medical code for each lab test performed, it is leaving some details up to each HCFA Medicare carrier.
For example, HCFA has introduced four chemistry panels, which a physician may order without having to include medical codes. These four panels are supposed to replace about 18 automated test series that physicians have been using. (See description of four new panels, above.)
But different Medicare carriers might decide to allow physicians to continue using some of these test series without diagnosis codes, and others might not. No one knows how stringently the new rule will be enforced, says Vincent Stine, government affairs manager with the American Association for Clinical Chemistry of Washington, DC. The AACC is a nonprofit organization that represents clinical chemists who work in the hospital industry and independent laboratories.
Stine says HCFA made the change to cut down on unnecessary tests, which increase medical costs. Physicians had become accustomed to ordering panels of tests that include analyses of chemicals that would have no relationship to a particular patient’s medical condition.
"A lot of times a physician was checking off this panel or that panel even though they didn’t need all that information," Stine explains. "They were just ordering it because they were used to ordering it."
At least one major laboratory has decided to expect the worst.
Lab only accepting HCFA-approved profiles
Medical Laboratories of Virginia in Fredericks-burg, VA, has notified physicians and home care agencies that starting Jan. 1, 1998, the laboratory will no longer accept chemistry profiles other than the four approved by HCFA.
The laboratory still will conduct individual tests, but each must be ordered separately and include an ICD-9 diagnostic code or written diagnosis.
"Some institutions are still providing the larger panels, but we’re not going to do so because the documentation that’s needed to get coverage on this is just unbelievable," says Irene Valentino, MT, ASCP, assistant lab manager at Medical Laboratories of Virginia.
"We sent our information sheet on this to home health agencies, and I’m going around personally to home health agencies to explain the situation to them," Valentino adds.
The company started accepting the new HCFA panels as of Oct. 1, but these will not be mandatory until Jan. 1, 1998, because physicians and other health care providers will need some time to adjust, says Paul Hine, MD, medical director of Medical Laboratories of Virginia.
"There will be a learning curve for sure," Hine says. "There will need to be a lot of interaction between the laboratory and physician’s office to clarify the guidelines," he adds.
Stine says the Balanced Budget Act of 1997 requires physicians to provide the appropriate diagnosis code to the provider or laboratory at the time the doctor orders the test.
A medical code for every lab test
This task may place an extra burden on home health nurses because some agencies have simply taken the physician’s lab test order over the telephone, and the nurse has had to fill out the ICD-9 code. Hine says his company is interpreting the new law to mean that only the physician can fill out this code.
Medical Innovations has been educating nurses about the new rules, stressing how important it is that nurses make sure there’s a medical code on every lab test except for the four approved panels, Bryant says.
She gives this example of how a health care provider easily could make a mistake in selecting the proper medical code:
A home health nurse might be drawing regular blood samples of a patient who had a closed head injury. The physician ordered the sample to check for levels of dilantin, a seizure medicine, Bryant explains.
Then suddenly the patient contracts a urinary tract infection, and the physician calls to ask the agency to draw urine to test for the infection. So if the physician writes on the lab slip that the primary diagnosis code is the patient’s head injury, then Medicare or the lab would send that back. They would want to know why a urine sample is medically necessary for a head injury. The correct code would have referred to a urinary tract infection.
Must check specimens for proper labeling
Medical Innovations’ nurses also are continually reminded to ask the laboratory technicians to check their specimens and make certain they’re labeled properly.
"If you don’t label the tube correctly, then the lab won’t accept it," Bryant says. "And you’ve done all this work and will have to go back and stick the patient again for another sample."
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