Clinical lab agreement called victory for physicians
Late last month, members of the Health Care Financing Administration's (HCFA) Clinical Laboratory Negotiated Rulemaking Committee agreed to a new streamlined approach to laboratory billing rules that could limit the ability of federal investigators to rummage through your billing records.
The agreement ended 14 months of negotiations between HCFA and the committee, composed of a number of leading health care organizations, including the Medical Group Management Association, the American Medical Association, the American Medical Group Association, the American Hospital Association, and the American Health and Information Management Association.
The committee's draft proposal includes the following items:
- Documentation and record keeping.
— The ordering physician must only maintain documentation of medical necessity in the beneficiary's medical record.
— The ordering physician's signature is not required on the requisition form.
— Upon post-payment review, the request for information should be streamlined.
— If the entity submitting the claim requests additional diagnostic information from the ordering physician, it must adhere to existing confidentiality standards.
Most significantly, according to the proposal, in a post-payment review, contractors can't go on a fishing expedition through every file in the physician's practice. The information they request in a particular case must be limited to material relevant to establishing the medical necessity of the service that was provided.
"Physicians and administrators want to comply and be helpful to investigators," says Rayna Richardson, a government affairs specialist with the Medical Group Management Association in Englewood, CO. "But at the same time, we felt that it was important that requests [for information] be streamlined and in writing. And we ended up getting that."
- Claims processing.
— Medicare contractors whose systems accept less than eight ICD-9-CM codes must permit entities submitting claims to put additional codes in the narrative field.
— Laboratories are allowed to assign a diagnosis code to a narrative, even if the wording of the narrative does not exactly match the code descriptor for the ICD-9-CM code.
— HCFA is required to instruct its contractors to refrain from denying claims solely because there is no matching of diagnosis and procedure codes on the claim form.
- Systems changes.
— HCFA is required to provide a grace period of not more than 12 months after the effective date of the final rule to accommodate any system changes required by the new policy.
The biggest winners are likely to be large group practices that cross Medicare contractor boundaries, Richardson says. "In the past, each contractor could have handled some administrative issues differently, and now there will be national consistencies."
Local problems concerning contractors whose policies vary sharply from national norms will also be ironed out as a result of the national standards, she adds.
HCFA is expected to publish a proposed rule based on the negotiated agreement by late November or early December, Richardson says. A comment period will follow, after which the committee may be reconvened to consider possible revisions. If all goes well, a final rule could come out as early as next spring, followed by the 12-month grace period for system changes.
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