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Who's Watching Your Wallet?

Vachette Monthly, July 2020

Understanding UHC's lab test registryBeginning Oct. 1, United Healthcare (UHC) will require labs to provide unique test codes on claims for in-scope services. In order to comply, lab providers must register their lab tests BEFORE Sept. 1, 2020.

Lab test codes must be on claims for in-scope lab test services. The codes will serve as the lab’s unique identifier that a physician would use to order a test (aka “test code, “order code, or “test identifier”). Claims without the codes may be denied.

According to UHC’s provider FAQ: “a laboratory test code is a laboratory’s unique identifier that a physician would use to order a test. This should uniquely identify the test offered by the laboratory and correspond to what the physician ordered, whether it was a single test that is ultimately billed as a single procedure code or a test “panel” that ultimately bills as multiple procedure codes.”

Laboratory testing services covered by this protocol include ALL freestanding and outpatient hospital laboratory testing services EXCEPT for:

• Lab test services requiring notification/prior authorization by theGenetic and Molecular Lab Testing Notification/PriorAuthorization Process.

• Lab test services requiring placement of the National Institutes ofHealth (NIH) Genetic Testing Registry (GTR) ID (per UHC’sMolecular Pathology Reimbursement policy).

• Lab test services rendered by outpatient physician officelaboratories (i.e., those billing place of service 11).

This means place of service 81 (independent labs) and 22 (outpatient) are included under this protocol if they are in-network with UHC.

The Billing BreakdownWelcome to The Billing Breakdown, a recurring column where we aim to highlight pathology and clinical lab billing issues that we encounter both in discussions with our clients and through our billing audits. These items are identified by Jennifer Martin, Vachette's Director of Special Audits.

For providers seeking payment through the HRSA Uninsured Program for COVID-19 testing: claims for uninsured patients will be reimbursed IF one of the following three diagnoses codes is included anywhere on the claim:

• Z03.818 – Encounter forobservation for suspected exposureto other biological agents ruled out.(possible exposure to COVID-19

• Z11.59 – Encounter for screeningfor other viral diseases(asymptomatic).

• Z20.828 – Contact with and(suspected) exposure to other viralcommunicable (confirmed exposureto COVID-19.

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At Vachette, we specialize in consulting and auditing for labs and pathology practicesWe have been working with hospitals, laboratories, and hospital-based groups for more than 18 years. Visit vachettepathology.com, call 517-486-4262, or contact Dustin Suntheimer, vice president of sales and marketing, at 734-972-2693. Our experience and expertise are second to none!

Is Medicare still applying the 2% sequestration to your claims, despite its

suspension through 2020? Be sure to check!Don't forget, if you

received a second round of HHS relief fund payments, you must attest again to

the terms and conditions of acceptance!

Don't miss our next COVID-19 webinar on July 15!We're hosting our third free webinar on COVID-19 payment issues at 3 p.m., Wednesday, July 15. The session will feature Lighthouse Lab Services President Jon Harol as a guest speaker who will provide an overview on how the lab industry at large is being affected and how to validate your lab and equipment for testing. Other issues to be covered include UHC's new lab test registry and updates on several provider/business funds. Head to our website to sign up!

OIG monitoring COVID add-on testingThe OIG recently announced it will be closely monitoring Medicare COVID-19 claims data for lab testing to find trends in the use of RPP, allergy, and genetic testing and identify patterns of billing by labs that may indicate fraud and abuse. This is something to keep in mind if you're performing and billing these add-on services for COVID patients.

CMS expanding MIPS exceptions for labs impacted by COVID-19

Looking to opt out of QPP/MIPS for 2020? CMS recently announced it is extending its Extreme and Uncontrollable Circumstances Application to anyone who has been "significantly" impacted by the COVID-19 public health emergency. We're currently seeking clarification on exactly what criteria CMS will base these exceptions off, but anyone who is approved will be eligible to ignore reporting and subsequently receive a neutral payment adjustment in 2022.

While this is good news, One potential side effect of CMS's decision to broaden its exceptions for 2020 reporting is that it could greatly affect the potential bonus pool if a large number of participants choose to opt-out. With bonuses and penalties set to reach +/-9%, in addition to the rising performance threshold, this was finally the year when many predicted significant bonuses would be available. Now, with a potentially smaller penalty pool to draw from, we may continue to see paltry bonus payouts...

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Medicare still requires medical necessity for COVID-19 testingAs more and more asymptomatic individuals seek COVID-19 tests, or receive them prior to elective procedures, it's important to remember that Medicare has still not waived the medical necessity requirement for these tests.

Furthermore, while commercial payers are required under the CARES Act to cover all testing without cost-sharing, we've still seen a number of instances where these payers denied claims.

In short, which payers cover testing and when is quickly becoming a gray area for providers, which is why they must be prepared to appeal denials for these crucial services.

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Our expert staff provides primary diagnoses, subspecialty

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HHS clarifies data labs must submit for COVID-19 testingLast month, the Department of Health and Human Services (HHS) issued additional guidance for labs and other entities performing COVID-19 testing regarding exactly what demographic data is required to be submitted to local health authorities.

While these requirements fall under the CARES Act, HHS felt additional guidance was necessary to show exactly what data is required to be submitted and what information is only being requested on a voluntary basis. The guidance acknowledges that since this data is beyond what has traditionally been requested, labs have until Aug. 1, 2020 to report it to the appropriate entity.

These are the 18 data points that HHS clarified MUST be reported to the CDC (typically through state and local health departments) for SARS-CoV-2 lab tests. They should be reported within 24 hours of results being known or determined, on a daily basis to the appropriate state or local public health department based on the patient’s residence.

• 1. Test ordered – use harmonized LOINC codes provided by CDC / 2. Device Identifier / 3. Test result – use appropriate LOINC and SNOMED codes, as defined by the Laboratory In Vitro Diagnostics (LIVD) Test Code Mapping for SARS-CoV-2 Tests provided by CDC / 4. Test Result date (date format) / 5. Accession # or Specimen ID / 6. Patient age / 7. Patient race / 8. Patient ethnicity / 9. Patient sex / 10. Patient residence zip code / 11. Patient residence county / 12. Ordering provider name and NPI (as applicable) / 13. Ordering provider zip / 14. Performing facility name and/or CLIA number, if known / 15. Performing facility zip code / 16. Specimen Source – use appropriate LOINC, SNOMED-CT, or SPM4 codes, or equivalently detailed alternative codes / 17. Date test ordered (date format) / 18. Date specimen collected (date format)

These standards also apply to home-based testing. --COVID-19 Data, 4

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--COVID-19 reporting data, continuedThe problem is that many labs do not receive information such as race or ethnicity with a patient’s EHR file, placing them in a bind for how exactly to collect this data. Further complicating matters, the guidance issued by HHS isn’t exactly clear on how labs can backtrack to obtain this info if it’s not provided in a patient’s record. The document simply states the following:

“…any person or entity ordering a diagnostic or serologic test, collecting a specimen, or performing a test should make every reasonable effort to collect complete demographic information and should include such data when ordering a laboratory test to enable the entities performing the test to report these data to state and local public health departments. When information is not available, ordering health care providers (or their designees), laboratories performing SARS-CoV-2 and associated tests, and State Public Health departments should consider leveraging resources like state or regional HIEs and National Health Information Networks (HIN) to obtain missing, required information.”

It’s currently unclear exactly what penalties labs that fail to collect and submit all required data may face. However, those penalties, if enforced, would most likely be done at the state level, meaning labs could face a patchwork of consequences depending on where they operate.

Additionally, HHS is also encouraging labs to report the following data points. However, they are not required.

Patient name (Last name, First name, Middle Initial) / Patient street address / Patient phone number with area code / Patient date of birth / Ordering provider address / Ordering provider phone number.